A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take?
a. Document that the asp...
A patient who has a history of a transient ischemic attack (TIA) has an
order for aspirin 160 mg daily. When the nurse is administering the
medications, the patient says, "I don't need the aspirin today. I don't
have any aches or pains." Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Call the health care provider to clarify the medication order.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Tell the patient that the aspirin is used to prevent aches. C
A patient newly diagnosed with Crohn's disease asks the nurse what to
expect in the future. The best response by the nurse is,
a. "You need to know that there is the probability of lifelong,
unpredictable periods of remissions and recurrences."
b. "You can expect to lead a normal life and may have long periods
without episodes of diarrhea or other symptoms."
c. "Most patients with Crohn's disease require an ostomy to control the
disease, but you can adjust to that."
d. "After about 10 years, patients with Crohn's disease have a high risk
for colon cancer unless the colon is removed." A
,Following bowel surgery 2 days ago, a patient has been receiving
normal saline intravenously at 100 ml/hr, has a nasogastric tube to low,
intermittent suction, and is NPO. An assessment finding that indicates a
need to contact the health care provider immediately is a
a. weight gain of 2 pounds above the preoperative weight.
b. an oral temperature of 100.1° F with bibasilar lung crackles.
c. gradually decreasing level of consciousness (LOC).
d. serum sodium level of 138 mEq/L (138 mmol/L). C
While caring for a patient with abdominal surgery the first
postoperative day, the nurse notices new bright-red drainage about 6
cm in diameter on the dressing. In response to this finding, the nurse
should initially
a. take the patient's vital signs.
b. notify the patient's surgeon of a potential hemorrhage.
c. reinforce the dressing.
d. recheck the dressing in 1 hour for increased drainage. A
A 42-year-old patient recently developed abdominal distention, weight
loss, steatorrhea, and flatulence. A diagnosis of adult celiac disease is
made, and treatment is initiated. The nurse determines that teaching
about the treatment of the disease has been effective when the patient
says,
a. "I must take folic acid for the rest of my life."
b. "I will avoid dietary wheat, rye, barley, and oats."
, c. "I will be sure to take all of the ordered antibiotics."
d. "I should eat only very low-fat or fat-free foods." B
The RN and nursing assistant (NA) are caring for a patient with a
paralytic ileus. Which of these nursing activities is appropriate for the
nurse to delegate to the NA?
a. Irrigation of the NG tube with saline
b. Retaping the NG tube
c. Applying petroleum jelly to the lips
d. Auscultation for bowel sounds C
What nursing action addresses the age-related changes of sensory
perception for an older adult client admitted to a general medical floor?
a. Using a call button that requires only minimal pressure to activate
b. Providing a clock and calendar to minimize dementia onset
c. Ensuring that paths are free from equipment
d. Admitting the client to the room closest to the nursing station C
A client who experienced a spinal cord injury 1 hour ago is brought to
the emergency room. Which medication should the nurse prepare to
administer to this client?
a. Intrathecal baclofen
b. Methylprednisolone
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