The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.
- A. Avoid driving while taking this medicine
- B. Change positions slowly
- C. Discontinue immediately if suicidal thoughts occur
- D. Notify the health care provider of tarry stools
- E. Take the medicine with food
Correct Answer: D,E
Rationale: Tarry stools indicate potential GI bleeding, a serious naproxen side effect, and taking with food reduces GI irritation. Driving, position changes, and suicidal thoughts are not primary concerns with naproxen.
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The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s
- A. anterior fontanel
- B. bilateral hearing
- C. pulse pressure
- D. Babinski reflex
Correct Answer: A
Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.
A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?
- A. 800
- B. 1080
- C. 1440
- D. 1960
Correct Answer: C
Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.
A client at 20 weeks gestation reports 'running to the bathroom all the time,' pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
- A. Are you having any pain in your lower back or flank area?
- B. Do you wipe from front to back after urinating?
- C. Have you found that you urinate more frequently since becoming pregnant?
- D. Have you had a urinary tract infection in the past?
Correct Answer: A
Rationale: Back or flank pain suggests pyelonephritis, a serious complication of UTI in pregnancy, requiring urgent evaluation. Hygiene, frequency, and history are relevant but less critical than assessing for systemic infection.
The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the
- A. air leak gauge
- B. collection chamber
- C. water seal chamber
- D. suction control chamber
Correct Answer: D
Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.
The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.