The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to:
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Solution
Answer D is correct. Aspirin prevents the platelets from clumping together to prevent clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
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Solution
Answer B is correct. The contrast media used during an intravenous pyelogram contains iodine, which can result in an anaphylactic reaction. Answers A, C, and D do not relate specifically to the test; therefore, they are incorrect.
The primary cause of anemia in a client with chronic renal failure is:
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Solution
Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect.
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
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Solution
Answer D is correct. An adverse reaction to Myambutol is change in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer C is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
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Solution
Answer C is correct. Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions.
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
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Solution
Answer B is correct. An adverse reaction to Cognex is drug-induced hepatitis. The nurse should monitor the client for signs of jaundice. Answers A, C, and D are incorrect because they are not associated with the use of Cognex.
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
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Solution
Answer A is correct. Following extracorporeal lithotripsy, the urine will appear cherry red in color but will gradually change to clear urine. Answer B is incorrect because the urine will be red, not orange. Answer C is incorrect because the urine will be not be dark red or cloudy in appearance. Answer D is incorrect because it describes the urinary output of the client with acute glomerulonephritis.
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
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Solution
Answer B is correct. Coolness and discoloration of the reimplanted digits indicates compromised circulation, which should be reported immediately to the physician. The temperature should be monitored, but the client would receive antibiotics to prevent infection; therefore, answer A is incorrect. Answers C and D are expected following amputation and reimplantation; therefore, they are incorrect.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
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Solution
Answer D is correct. Tucking a disposable diaper at the perineal opening will help prevent soiling of the cast by urine and stool. Answer A is incorrect because the head of the bed should be elevated. Answer B is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer C is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast.
A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
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Solution
Answer C is correct. Depot injections of Haldol are administered every 4 weeks. Answers A and B are incorrect because the medication is still in the client’s system. Answer D is incorrect because the medication has been eliminated from the client’s system, which allows the symptoms of schizophrenia to return.