Nokea
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
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The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?
- A. Determine if the client has claustrophobia.
- B. Obtain a signed informed consent form.
- C. Determine if the client is allergic to egg yolks.
- D. Start an intravenous line in both hands.
Correct Answer: A
Rationale: MRI involves a confined space, so assessing for claustrophobia (A) ensures patient comfort and safety. Consent (B) is required but secondary, egg yolk allergy (C) is irrelevant, and bilateral IVs (D) are unnecessary.
The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
- A. Assess the client’s neurological status every hour.
- B. Monitor the client’s heart rhythm via telemetry.
- C. Administer an anticonvulsant medication by intravenous push.
- D. Prepare to administer a glucocorticosteroid orally.
Correct Answer: C
Rationale: Status epilepticus is a life-threatening continuous seizure requiring immediate IV anticonvulsants (C), such as lorazepam or phenytoin, to stop the seizure. Neurological assessment (A) and telemetry (B) are supportive, and glucocorticoids (D) are not indicated.
The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The assistant attempts to insert an oral airway.
- B. The assistant turns the client on the right side.
- C. The assistant has all the side rails padded and up.
- D. The assistant does not leave the client's bedside.
Correct Answer: A
Rationale: Inserting an oral airway during a seizure (A) risks injury and is contraindicated. Turning to the side (B), padding rails (C), and staying with the client (D) are appropriate.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.