Nokea
The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. Which of the following statements by the client would require follow-up?
- A. I will avoid taking over-the-counter aspirin.'
- B. I must avoid consuming green, leafy vegetables such as spinach and kale.'
- C. I should avoid consuming any caffeinated products.'
- D. I will talk with my health care provider before taking any nutritional supplements.'
Correct Answer: B
Rationale: Avoiding all green leafy vegetables (B) is incorrect; consistent intake is needed to maintain stable INR. Avoiding aspirin (A), caffeine (C), and consulting about supplements (D) are correct.
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Which of the following toys is the most appropriate for a 2-year old with Tetralogy of Fallot?
- A. A toy horn
- B. A stethoscope
- C. A push-pull toy
- D. A shape sorter
Correct Answer: C
Rationale: A push-pull toy encourages gentle physical activity suitable for a 2-year-old with Tetralogy of Fallot, who may tire easily. A toy horn requires exertion, a stethoscope is not age-appropriate, and a shape sorter is sedentary.
The nurse is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse administer to the client? Select all that apply.
- A. albuterol
- B. buproten
- C. ipratropium
- D. tobramycin
- E. montelukast
Correct Answer: A, C
Rationale: Albuterol (A) and ipratropium (C) are bronchodilators used in acute asthma exacerbations. Ibuprofen (B), tobramycin (D), and montelukast (E) are not indicated for acute management.
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?
- A. Assisting the parents in signing Against Medical Advice (AMA) papers
- B. Discharging the child if parents have power of attorney papers
- C. Notifying the hospital administration about the situation
- D. Reassuring the parents that their decision will be respected under the principle of autonomy
Correct Answer: C
Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (C) ensures legal and ethical intervention to protect the child. AMA (A), power of attorney (B), or respecting autonomy (D) are inappropriate for a minor.
The LPN/LVN is providing home care to an elderly widow who has senile dementia. The woman tells the nurse that her daughter hits her and tells her to shut up. The nurse notes one ecchymotic area on the client's right forearm. The daughter seems attentive to the woman when the nurse is present. What action should the nurse take?
- A. Immediately call the police
- B. Ask the daughter why she abuses her mother
- C. Ask the physician to order long bone x-rays
- D. Report the woman's remarks and the nurse's findings to the nursing supervisor
Correct Answer: D
Rationale: Reporting suspected abuse to the supervisor initiates investigation and protection, the appropriate action for potential elder abuse.
A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.