Nokea
The nurse is teaching a caregiver how to administer an injection of a prefilled syringe of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should expel the air bubble before administering."
- C. "Green leafy vegetables are allowed while taking this medication."
- D. "This medication may increase the risk for bleeding."
Correct Answer: B
Rationale: The air bubble in a prefilled enoxaparin syringe should not be expelled, as it ensures the full dose is administered.
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A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 mL of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well.
- C. Monitor the client for nausea, vomiting, and abdominal distention.
- D. Turn the machine to high suction if the drainage is sluggish on low suction.
Correct Answer: C
Rationale: Monitoring for nausea, vomiting, and abdominal distention is essential to detect complications such as obstruction or ileus. Routine irrigation, repositioning, or increasing suction without medical orders is unsafe.
Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
The nurse is observing a client who is recovering from back strain lift a box as shown below. What should the nurse do?
- A. Praise the client for using correct body mechanics.
- B. Suggest to the client that she put both knees on the floor before attempting to lift the box.
- C. Advise the client to bend from the waist rather than stretching her back in this position.
- D. Inform the client that she should keep her back straight by squatting with both knees parallel.
Correct Answer: A
Rationale: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.