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Questions 158

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Question 1 of 5

A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

Correct Answer: C

Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.

Question 2 of 5

Which of the following describes a positive Kernig's sign?

Correct Answer: A

Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.

Question 3 of 5

A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:

Correct Answer: B

Rationale: When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.

Question 4 of 5

The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?

Correct Answer: C

Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.

Question 5 of 5

Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

Correct Answer: D

Rationale: Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SO
B), and wheezing. Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. Epinephrine has the effect of bronchodilation through stimulation. Propranolol, esmolol, and labetalol are -blocking agents, which can increase airway resistance and cause bronchospasms.

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