Nokea
The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?
- A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm² (154 x 10â¹/L)
- B. Losartan for client with hypertension who is 8 weeks pregnant
- C. Prednisone for client with herpes simplex lesions and Bell palsy
- D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Losartan is contraindicated in pregnancy due to fetal harm risks. Clopidogrel is safe with normal platelet counts, prednisone is appropriate for Bell palsy, and tiotropium is suitable for COPD despite pneumonia.
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A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
- A. Ensure that informed consent has been obtained
- B. Place the client in reverse Trendelenburg position
- C. Place the client on NPO status
- D. Request the client empty their bladder
- E. Take baseline vital signs and weight
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.
The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:
- A. 68
- B. 76
- C. 98
- D. 120
Correct Answer: C
Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.
The nurse is caring for assigned clients. Which of the following clients is at highest risk for developing delirium?
- A. 32-year-old client with gastroenteritis, dehydration, and a low-grade fever
- B. 55-year-old client with coronary artery disease who had coronary artery bypass surgery four days ago
- C. 60-year-old client with type 2 diabetes mellitus who had bilateral above-the-knee amputations two months ago
- D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis
Correct Answer: D
Rationale: The 80-year-old with COPD, respiratory failure, and urosepsis has multiple delirium risk factors: advanced age, infection, and chronic illness. Younger clients with less severe conditions have lower risk.
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
- A. Nausea and vomiting
- B. Restlessness and confusion
- C. Low-grade fever and cough
- D. Irritating cough and liquefied sputum
Correct Answer: B
Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
A client returns from surgery after having a suprapubic prostatectomy. Upon assessing the client, the nurse notes that his urine is bright red with many clots. Which of the following nursing actions is most appropriate?
- A. Check the client's vital signs and notify the physician.
- B. Check whether the continuous irrigation is working properly.
- C. Recognize that this is a normal finding after surgery and continue post-op care.
- D. Apply traction on the catheter and notify the physician.
Correct Answer: B
Rationale: Bright red urine with clots suggests a need to check the continuous bladder irrigation system to ensure it is functioning to prevent clot obstruction.