Nokea
The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs (NSAIDs)
- B. Cough medicines with guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs). Medications with NSAIDs may increase the response to Coumadin (warfarin) and increase the risk of bleeding.
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A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
The nurse is using contact precautions when caring for the client. When changing the client's IV solution bag, the nurse inadvertently touches the end of the exposed spike of the tubing. Which is the most appropriate action by the nurse?
- A. Insert the spike into the new IV solution bag
- B. Remove the gloves and obtain another pair
- C. Discard the tubing and obtain another sterile tubing
- D. Use alcohol to cleanse the spike of the tubing
Correct Answer: C
Rationale: C: The contaminated spike requires new sterile tubing to prevent infection. A: Using contaminated tubing risks infection. B: Changing gloves doesn't address tubing contamination. D: Alcohol cannot sterilize the spike.
The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
- A. "Persons entering the room with colds should stay at least 3 feet from me."
- B. "My family plans to bring flowers from my garden to help me feel better."
- C. "The precautions will protect me and help my blood count recover faster."
- D. "Persons entering my room should perform hand hygiene before entering."
Correct Answer: D
Rationale: D: Hand hygiene is critical to prevent pathogen introduction. A: Visitors with colds should avoid entry. B: Flowers can harbor microbes. C: Precautions don't improve neutrophil counts.
Which of these findings would the nurse more closely associate with dehydration in a 10 month-old infant?
- A. Status of the eyes and the tongue
- B. Urine output
- C. Skin elasticity
- D. Dietary patterns
Correct Answer: A
Rationale: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.
The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?
- A. Hand the provider a gown and gloves
- B. Not say anything; it is the HCP's decision
- C. Notify the charge nurse and unit manager
- D. Monitor for increased infections on the unit
Correct Answer: A
Rationale: A: Providing PPE ensures immediate compliance with contact precautions. B: Ignoring the breach risks transmission. C, D: These actions delay intervention.