Nokea
What is the priority intervention for a client with a suspected stroke?
- A. Administer aspirin.
- B. Perform a CT scan.
- C. Monitor neurological status.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Monitoring neurological status is the priority to detect changes and guide timely stroke intervention.
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A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
- A. Coarse breath sounds auscultated bilaterally at the bases.
- B. Dusky appearance of the stoma.
- C. No drainage in the ostomy appliance.
- D. Temperature greater than 101.2°F (38.5°C).
- E. Decreased bowel sounds.
Correct Answer: B,C,D
Rationale: A dusky stoma (B) indicates poor blood supply, no drainage (C) suggests obstruction or dysfunction, and fever (D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.
A client with rheumatoid arthritis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which client statement indicates a need for further teaching?
- A. I'll take the medication with food.'
- B. I should report any stomach pain.'
- C. I can take ibuprofen with this drug.'
- D. I'll monitor for bruising or bleeding.'
Correct Answer: C
Rationale: Taking ibuprofen with another NSAID increases the risk of gastrointestinal bleeding, indicating a knowledge deficit.
A nurse is teaching a camp counselor about the treatment of snake bites to an extremity. Which of the following information should be included in the teaching?
- A. apply a tourniquet above the affected site
- B. keep the extremity elevated above the heart
- C. if possible, try to capture the snake for easy identification
- D. do not apply ice to the affected site
Correct Answer: D
Rationale: Applying ice can cause tissue damage and is not recommended. Tourniquets (A) can worsen outcomes, elevation above the heart (B) is controversial and not universally advised, and capturing the snake (C) is unsafe and unnecessary with modern antivenom protocols.
A client is admitted to the unit with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and I.V. heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
- A. Administering aspirin as ordered
- B. Encouraging green leafy vegetables in the diet
- C. Monitoring the client's prothrombin time (PT)
- D. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR)
Correct Answer: D
Rationale: Heparin therapy for DVT requires monitoring aPTT to ensure therapeutic anticoagulation (1.5–2.5 times baseline). INR is less relevant for heparin but may be monitored if transitioning to warfarin. Aspirin is not typically used, and green leafy vegetables (high in vitamin K) may affect warfarin, not heparin.