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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 successful,' 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.
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The nurse and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP?
- A. Monitor the continuous passive motion machine.
- B. Assist the client to the bedside commode.
- C. Feed the client the evening meal.
- D. Elevate the foot of the client's bed.
Correct Answer: C
Rationale: Feeding the client (C) is within the UAP’s scope and safe post-bypass. Monitoring CPM (A), assisting to commode (B), and elevating bed (D) require nursing judgment due to circulation concerns.
Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease?
- A. Clopidogrel.
- B. Streptokinase.
- C. Protamine sulfate.
- D. Enoxaparin.
Correct Answer: A
Rationale: Clopidogrel (A), an antiplatelet, is used in arterial occlusive disease to prevent thrombosis. Streptokinase (B) is a thrombolytic, protamine (C) reverses heparin, and enoxaparin (D) is for DVT.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply.
- A. Wash your feet in antimicrobial soap.
- B. Wear comfortable, well-fitting shoes.
- C. Cut your toenails in an arch.
- D. Keep the area between the toes dry.
- E. Use a heating pad when feet are cold.
Correct Answer: B,D
Rationale: Well-fitting shoes (B) prevent injury, and dry toes (D) prevent infection in PVD. Antimicrobial soap (A) is unnecessary, arched toenails (C) risk ingrown nails, and heating pads (E) risk burns.
The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client?
- A. Occupational therapist.
- B. Social worker.
- C. Physical therapist.
- D. Cardiac rehabilitation.
Correct Answer: B
Rationale: A social worker (B) coordinates home care for an elderly client with a chronic ulcer. OT (A) and PT (C) are less relevant, and cardiac rehab (D) is unrelated.
The client asks the nurse why they need to take a diuretic for hypertension. What is the best response?
- A. It helps your heart pump more efficiently.
- B. It reduces the amount of fluid in your blood vessels.
- C. It prevents blood clots from forming.
- D. It relaxes the blood vessel walls.
Correct Answer: B
Rationale: Diuretics reduce blood volume by increasing urine output, lowering pressure in blood vessels.