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The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply.
- A. It should be administered in the anterior area of the iliac crest.
- B. The onset is immediate.
- C. Use a 27G, 5/8€ needle.
- D. Cephalosporin potentiates the effects of heparin.
- E. Double check the dose with another nurse.
Correct Answer: C,E
Rationale: Subcutaneous heparin should be administered using a 27-gauge, 5/8-inch needle to ensure proper delivery into subcutaneous tissue. Due to the risk of bleeding, the dose should be double-checked with another nurse. The anterior iliac crest is not a standard site (abdomen is preferred), onset is not immediate (takes hours), and cephalosporins do not potentiate heparin's effects.
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Which medication requires monitoring for a client with Parkinson's disease?
- A. Antihypertensives.
- B. Levodopa.
- C. Antidepressants.
- D. Antihistamines.
Correct Answer: B
Rationale: Levodopa requires monitoring for efficacy and side effects, as it is a primary treatment for Parkinson's symptoms.
An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?
- A. Empty the catheter drainage bag.
- B. Cover the client with warm blankets.
- C. Hang new bags of irrigation.
- D. Turn the client.
Correct Answer: B
Rationale: Room-temperature irrigation can cause hypothermia, especially in an elderly client. Covering with warm blankets is the most important intervention to maintain normothermia.
Which of the following goals is a priority for a client who has undergone surgery for retinal detachment?
- A. Control pain.
- B. Prevent an increase in intraocular pressure.
- C. Follow a low-sodium diet.
- D. Maintain a darkened environment.
Correct Answer: B
Rationale: Preventing an increase in intraocular pressure is the priority to protect the surgical repair and prevent complications like re-detachment or hemorrhage.
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.