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Questions 164

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Extract:


Question 1 of 5

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?

Correct Answer: C

Rationale: Rivaroxaban is a direct oral anticoagulant that does not require routine monitoring of clotting levels, unlike warfarin. It also does not necessitate dietary restrictions like avoiding spinach and kale, which are relevant for warfarin due to vitamin K interactions. Avoiding aspirin is correct because it increases bleeding risk when combined with rivaroxaban. Weakness in legs is not a typical side effect of rivaroxaban.

Extract:

Vital signs
Temperature 98.7 F (37.05 C)
Blood pressure 110/64 mm Hg
Heart rate 92/min
Respirations 22/min
O2 saturation or SpO2 90% on room air


Question 2 of 5

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?

Correct Answer: A

Rationale: Observing the client (
A) allows assessment of the behavior's cause. Assuming dissatisfaction (
B) or dementia (
D) is premature. Leaving the client (
C) delays intervention.

Extract:


Question 3 of 5

The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjogren's syndrome. Which client statement indicates the need for further teaching?

Correct Answer: A

Rationale: Rubbing the eyes after applying ointment (
A) can cause irritation or displace the medication, indicating a need for further teaching. The other statements (B, C,
D) reflect correct administration techniques.

Question 4 of 5

The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs?

Correct Answer: B,D,E

Rationale: Peer visits (
B), active participation (
D), and addressing body image (E) support a teen's psychosocial needs. Strict schedules (
A) reduce autonomy, and parental presence (
C) may not align with the teen's preferences.

Extract:

Vital signs
Blood pressure 105/60 mm Hg
Heart rate 80/min
Respirations 22/min
SpO2 90% on room air
Nurse notes
The client has a history of coronary artery disease and peripheral vascular disease. Nursing assessment reveals crackles in middle & lower lung fields, moderate jugular venous distension, and 3+ pedal edema.
Medications
Enoxaparin: 30 mg subcutaneous once daily
Metoprolol: 50 mg PO twice a day
Furosemide: 40 mg PO twice daily
Atorvastatin: 20 mg PO once daily


Question 5 of 5

The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?

Correct Answer: D

Rationale: Metoprolol (
D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (
C) treats fluid overload, enoxaparin (
B) prevents thrombosis, and atorvastatin (
A) manages lipids.

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