Nokea
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who received a Mantoux test 48hr ago and has an induration
- B. A client who is schedule for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8(low INR clotting)
- D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.
Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care. Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care. Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L
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Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.
Which of the following prescriptions should the nurse clarify?
- A. Digoxen 250 PO daily
- B. Metoprolol 50 mg PO twice daily
- C. Furosemide 40 mg IV once daily
- D. Acetaminophen 650 mg PO every 6 hours PRN pain
Correct Answer: A
Rationale: The correct answer is A. Digoxin is commonly prescribed in mcg, not mg. Therefore, the nurse should clarify the dosage unit. Metoprolol (B) is a typical dose and frequency for oral administration. Furosemide (C) is a standard dose and route for IV administration. Acetaminophen (D) is a common dose and frequency for pain management. The other choices are not problematic.
Which client statement should the nurse report as an indication of major depressive disorder?
- A. I am unable to feel any joy since my child died
- B. I have lost interest in activities I once enjoyed.
- C. I have trouble sleeping and have no appetite.
- D. I feel guilty and worthless every day.
- E. I have been thinking about ending my own life.
Correct Answer: E
Rationale: The correct answer is E because suicidal ideation is a significant red flag for major depressive disorder. This statement indicates severe emotional distress and potential risk for self-harm. Choices A, B, C, and D are common symptoms of depression but do not necessarily point to the severity and immediate risk of suicide like choice E does. Reporting suicidal thoughts is crucial for timely intervention and ensuring the client's safety.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
In which of the following positions should the nurse place the client immediately following the procedure?
- A. Trendelenburg
- B. Prone
- C. Right lateral
- D. High-fowlers
Correct Answer: C
Rationale: The correct answer is C: Right lateral. Placing the client in the right lateral position immediately following a procedure helps prevent aspiration of secretions or blood, as gravity assists in drainage from the airway. Trendelenburg position (A) is used to increase venous return but is not appropriate post-procedure. Prone position (B) is lying face down and may obstruct airway patency. High-fowlers position (D) is sitting upright at a 90-degree angle, which is not ideal for immediate post-procedure care.