Nokea
The nurse is working in a surgeon's office and talking with a client who is scheduled for surgery in two weeks. The nurse asks about medications and supplements the client may be taking. What medication(s) the client reports would be of most concern to the nurse? Select all that apply.
- A. Acetaminophen
- B. Ibuprofen
- C. Vitamin C
- D. Vitamin E
- E. Ginseng
- F. Vitamin B complex
Correct Answer: B,D,E
Rationale: Ibuprofen, Vitamin E, and ginseng increase bleeding risk, posing concerns for surgical hemostasis.
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The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I eat a salad with spinach every day.
- B. I take ibuprofen for my headaches.
- C. I drink a glass of red wine with dinner.
- D. I walk for 30 minutes every morning.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.
The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse would be to inform them that
- A. Circumcision is delayed so the foreskin can be used for the surgical repair
- B. This procedure is contraindicated because of the permanent defect
- C. There is no medical indication for performing a circumcision on any child
- D. The procedure should be performed as soon as the infant is stable
Correct Answer: A
Rationale: Circumcision is delayed so the foreskin can be used for the surgical repair. Even if only mild hypospadias is suspected, circumcision is not done to save the foreskin for surgical repair.
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance imaging?
- A. The client is an insulin-dependent diabetic.
- B. The client refuses a corner bed.
- C. The client is allergic to shellfish.
- D. The client has a history of asthma.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for MRI contrast dye, requiring further assessment. Diabetes , bed preference , and asthma are not contraindications.
A child admitted with failure to thrive has just had a positive sweat Test .
The nurse would anticipate which of the following changes in the child's plan of care initially?
- A. Administration of replacement enzymes.
- B. Administration of oxygen.
- C. A salt-restricted diet.
- D. Initiate intravenous therapy.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-sweat Test is a positive finding for cystic fibrosis (2) no data in this situation to indicate that the child is having pulmonary problems (3) salt is increased in diet (4) no need for IV therapy based on the data in situation