Nokea
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.
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A client with a history of rheumatoid arthritis is prescribed leflunomide (Arava). The nurse should monitor the client for which of the following side effects?
- A. Liver toxicity.
- B. Hypotension.
- C. Weight loss.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Leflunomide can cause liver toxicity, requiring regular monitoring of liver function tests.
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?
- A. Case manager
- B. Collaborator
- C. Coordinator of care
- D. Advocacy
Correct Answer: D
Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
A client diagnosed with chronic kidney disease has been prescribed epoetin alfa. The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy?
- A. Ferrous gluconate
- B. Calcium carbonate
- C. Aluminum carbonate
- D. Aluminum hydroxide gel
Correct Answer: A
Rationale: To form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate stores of iron, folic acid, and vitamin B12. The client should take these ferrous gluconate supplements regularly to enhance the hematocrit-raising benefit of this medication. The other options are unnecessary medications.