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Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individual who have had a stroke
- B. obtaining an alert system to get help in case of a fall
- C. providing information about available transportation resources
- D. choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: obtaining an alert system to get help in case of a fall. This is the priority for the nurse to discuss because falls can lead to serious injuries, so having a system in place to quickly get help is crucial for the patient's safety. Reviewing support groups (A) is important but not as urgent as fall prevention. Transportation resources (C) and home physical therapy agency (D) are important but secondary to immediate safety concerns.
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Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
Select the findings that indicate the client is experiencing adverse effects of the medication.
- A. Client states, 'I am feeling much better'
- B. Difficulty sleeping
- C. Client continues to deny any suicidal ideation
- D. BP 169/91 mm HG
- E. Respiratory rate 18/min
Correct Answer: B,D
Rationale: Hypertension and difficulty sleeping are potential side effects of certain medications.
Which of the following medications should the nurse identify as being incompatible with warfarin?
- A. Naproxen
- B. Metformin
- C. Lisinopril
- D. Albuterol
Correct Answer: A
Rationale: The correct answer is A: Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin, an anticoagulant. This is due to their combined effects on blood clotting. Metformin, Lisinopril, and Albuterol do not have a significant interaction with warfarin in terms of bleeding risk. Therefore, the nurse should identify Naproxen as incompatible with warfarin to prevent potential adverse effects.
Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.
The nurse should expect the adolescent to be in which of the following of erikson stages of psychosocial development.
- A. Identity versus role confusion
- B. Autonomy versus shame and doubt
- C. Initiative versus guilt
- D. Intimacy versus isolation
Correct Answer: A
Rationale: The correct answer is A: Identity versus role confusion. During adolescence, individuals are in Erikson's stage of developing a sense of identity and may struggle with role confusion. This stage typically occurs during the teenage years, where adolescents are exploring their personal values, beliefs, and goals. They are trying to establish a sense of self and may question their identity and place in the world. Choices B, C, and D are incorrect because Autonomy versus shame and doubt relates to toddlers, Initiative versus guilt relates to preschoolers, and Intimacy versus isolation relates to young adults. This makes A the most appropriate choice for an adolescent's stage of psychosocial development.