Nokea
What are the nursing considerations for a patient receiving anticoagulant therapy?
- A. Monitor INR levels and check for bleeding
- B. Educate patient on dietary restrictions
- C. Ensure adequate hydration and nutrition
- D. Ensure that the patient remains immobile
Correct Answer: A
Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.
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A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?
- A. Low birth weight
- B. Advanced maternal age
- C. Single parenthood
- D. Premature birth
Correct Answer: A
Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Weight gain.
- B. Dry mouth.
- C. Sedation.
- D. Shuffling gait.
Correct Answer: D
Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.
What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct Answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.
A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?
- A. Turn the client onto their left side
- B. Irrigate the NG tube with sterile water
- C. Increase the suction pressure to relieve the blockage
- D. Remove the NG tube and replace it with a new one
Correct Answer: B
Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Elevated blood glucose.
- B. Decreased urine output.
- C. Dependent edema.
- D. Jaundice.
Correct Answer: C
Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.