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When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
- A. Weekly Z-track injections are required for control.
- B. Daily intramuscular injections are required for control.
- C. Intramuscular injections once a month will maintain control.
- D. Oral tablets of vitamin B12 taken daily will keep the symptoms under control.
Correct Answer: C
Rationale: Monthly B12 injections maintain control in pernicious anemia due to absorption deficits.
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The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury.
The nurse is providing discharge teaching for a client with a history of alcoholism. Which of the following statements, if made by the client, indicates that the client understands the teaching?
- A. I should avoid all products that contain alcohol, including cough medicines.'
- B. I can have one drink a week as long as I dilute it with water.'
- C. I should continue to drink nonalcoholic beer to satisfy my taste for beer.'
- D. I can stop taking disulfiram (Antabuse) once I feel better.'
Correct Answer: A
Rationale: Complete abstinence is required for alcoholism recovery, including avoiding alcohol-containing products like cough medicines, which could trigger relapse. Diluted drinks (B) or nonalcoholic beer (C) risk relapse due to taste cues, and stopping disulfiram prematurely (D) increases relapse risk.
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.
The nurse is assigned to a patient newly diagnosed with active tuberculosis.
Which of these interventions would be a priority for the nurse to implement?
- A. Have the client cough into a tissue and dispose in a separate bag
- B. Instruct the client to cover the mouth with a tissue when coughing
- C. Reinforce that everyone should wash their hands before and after entering the room
- D. Place client in a negative pressure private room and have all who enter the room use masks with shields
Correct Answer: D
Rationale: A negative pressure room and masks prevent airborne transmission of tuberculosis, a priority for infection control.
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
- A. Family history of pressure ulcers
- B. Presence of existing pressure ulcers
- C. Potential areas of pressure ulcer development
- D. Overall risk of developing pressure ulcers
Correct Answer: D
Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.