Nokea
The unlicensed assistive personnel (UAP) is applying elastic compression stockings to the client. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The UAP is putting the stockings on while the client is in the chair.
- B. The UAP inserted two (2) fingers under the proximal end of the stocking.
- C. The UAP elevated the feet while lying down prior to putting on the stockings.
- D. The UAP made sure the toes were warm after putting the stockings on.
Correct Answer: A
Rationale: Applying stockings in a chair (A) is incorrect; legs should be elevated to reduce edema. Two fingers (B) ensures fit, elevation (C) is correct, and warm toes (D) is appropriate.
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The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
The nurse is caring for a male client diagnosed with essential hypertension. Which information regarding antihypertensive medication should the nurse teach?
- A. Teach the client to take his blood pressure four (4) times each day.
- B. Instruct the client to have regular blood levels of the medication checked.
- C. Explain the need to rise slowly from a lying or sitting position.
- D. Demonstrate how to use a blood glucose meter daily.
Correct Answer: C
Rationale: Antihypertensives cause orthostatic hypotension; rising slowly (C) prevents falls. Frequent BP checks (A) are excessive, drug levels (B) are rarely monitored, and glucose meters (D) are irrelevant.
The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?
Correct Answer: 1.5
Rationale: Dose required: 7.5 mg. Available: 5 mg/tablet. 7.5 ÷ 5 = 1.5 tablets. Administer 1.5 tablets (e.g., one whole and one half, if scored).
The client with endocarditis asks why they need IV antibiotics. What is the best response?
- A. They work faster than oral antibiotics.
- B. They are cheaper than oral forms.
- C. They prevent stomach upset.
- D. They are easier to take.
Correct Answer: A
Rationale: IV antibiotics achieve higher blood levels to effectively treat the infection in endocarditis.