Nokea
The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?
- A. Mild bruising or redness may occur at the injection site.
- B. Eliminate green, leafy, vitamin K-rich vegetables from your diet.
- C. Black stools are a common, harmless adverse effect of the medication.
- D. Take over-the-counter medications such as ibuprofen to relieve mild discomfort.
Correct Answer: A
Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.
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An adult who recently had an amputation has an above-the-knee prosthesis. Which nursing action will do the most to help the client adjust to the prosthesis?
- A. Adjust the prosthesis for the client.
- B. Offer the client a cane or a walker for ease of movement.
- C. Place an 'at risk for fall' sign on the client's door.
- D. Allow the client to manage his own care.
Correct Answer: D
Rationale: Allowing self-management fosters independence and confidence with the prosthesis, promoting adjustment.
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.
The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect?
- A. Blood glucose of 95 mg/dL (5.3 mmol/L)
- B. Potassium level of 4.2 mEq/L (4.2 mmol/L)
- C. Reduction in dizziness
- D. Sodium level of 138 mEq/L (138 mmol/L)
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so a normal potassium level indicates it is counteracting the potassium loss from hydrochlorothiazide.
A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction?
- A. I should leave the harness on during diaper changes.
- B. I will adjust the harness straps every 3-5 days.
- C. I will inspect the skin under the straps 2-3 times daily.
- D. The harness should keep my baby's legs bent and spread apart.
Correct Answer: B
Rationale: The harness straps should only be adjusted by a healthcare provider to ensure proper fit and treatment efficacy. Other statements reflect correct understanding of harness care.
The mother of a 1-week-old infant says to the nurse, 'When will that ugly black cord thing come off?' How should the nurse reply?
- A. Are you wiping it with alcohol each time you change the baby's diaper?'
- B. It usually comes off in 10 days to three weeks.'
- C. It sounds as if it bothers you. Would you like to talk about it?'
- D. It should be off by now. I'll have the doctor check to be sure there is no problem.'
Correct Answer: B
Rationale: The umbilical cord typically detaches in 10 days to 3 weeks, providing accurate information. Other responses are irrelevant or incorrect.