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The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
- A. Check that the dose is appropriate for the child's weight.
- B. Note that the onset of the medication will be immediate.
- C. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
- D. Monitor partial thromboplastin time (PTT).
- E. Discontinue the penicillin until the PTT is at a therapeutic level.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
The nurse is caring for a client with a suspected stroke. Which assessment should the nurse perform first?
- A. Check blood glucose levels
- B. Assess pupil response
- C. Evaluate speech and motor function
- D. Monitor blood pressure
Correct Answer: C
Rationale: Evaluating speech and motor function first helps confirm stroke symptoms using tools like the FAST scale, guiding urgent intervention.
A client with a urinary tract infection is prescribed ciprofloxacin. What should the nurse include in the teaching?
- A. Take the medication with dairy products.
- B. Report tendon pain or swelling.
- C. Increase fluid intake to 1 L/day.
- D. Avoid sunlight exposure completely.
Correct Answer: B
Rationale: Ciprofloxacin can cause tendonitis or tendon rupture, so reporting tendon pain or swelling is critical.
A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?
- A. Weight loss.
- B. Agranulocytosis.
- C. Hyperglycemia.
- D. Dry skin.
Correct Answer: B
Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.
A client with a history of breast cancer is prescribed letrozole (Femara). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Letrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.