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Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
- A. Tinnitus
- B. Ecchymoses
- C. Increased pulse rate
- D. Decreased blood pressure
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
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Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
- A. 3,4,2,1,5,6
- B. 3,4,5,1,2,6
- C. 2,3,5,1,4,6
- D. 3,2,4,1,5,6
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
A client with a diagnosis of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following serious side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Dry mouth.
- D. Insomnia.
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, a life-threatening reduction in white blood cells, requiring regular monitoring of white cell counts.
The charge nurse on an antepartal unit is preparing to complete assignments for the day. There is an RN, licensed practical nurse (LPN), and an unlicensed personnel (UAP) to care for 25 clients. The nurse should assign which of the following clients to the:
- A. A newly admitted G5 P2 Ab 2 with second trimester bleeding, reportedly currently saturating 1-2 pads in 12 hours.
- B. A 22-year-old G2 P1 with urinary retention who is being catheterized with an intermittent in and out every 4 to 6 hours p.r.n. while awaiting urine cultures to be returned.
- C. A G4 P2 with a twin pregnancy who was admitted in preterm labor and is now able to ambulate 2 to 3 times daily and having no contractions.
- D. A 30-year-old G4 P0 who was admitted in sickle unless currently receiving blood and pain medication.
Correct Answer: C
Rationale: The client with a stable twin pregnancy who is ambulating and has no contractions can be assigned to the LPN or UAP, as this client requires less complex care compared to others with active medical issues.
The nurse is teaching a client with a new diagnosis of asthma about inhaler use. Which of the following instructions should be included for a metered-dose inhaler?
- A. Shake the inhaler before use.
- B. Hold breath for 10 seconds after inhalation.
- C. Rinse the mouth after each use.
- D. Use a spacer if prescribed.
Correct Answer: A, B, D
Rationale: Shaking the inhaler, holding breath, and using a spacer ensure effective medication delivery.
As the registered nurse in the emergency department, you are taking care of an adolescent client who had just fractured their femur during gymnasium class at their high school. After casting, you will be discharging the client with crutches. Which of the following client goals that is paired with its learning domain should be included in the patient teaching plan for this client and the parents?
- A. Psychomotor domain: The client will slightly bend their elbows when holding the hand grips.
- B. Psychomotor domain: The client will rest their weight on the padded areas on the top of the crutches.
- C. Cognitive domain: The client will slightly bend their elbows when holding the hand grips.
- D. Cognitive domain: The nurse will tell the client how often the tips on the crutches must be replaced.
Correct Answer: A
Rationale: Proper crutch use involves psychomotor skills, such as slightly bending the elbows when holding the hand grips, to ensure safe and effective mobility.