the charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the
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1. The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?

Correct answer: A

Rationale: The correct action for the charge nurse to take is to remove the glass of water and speak to the UAP. This ensures immediate correction and education to prevent further issues with the nasogastric tube. Addressing the situation promptly can prevent harm to the client and reinforces the importance of following proper protocols.

2. A client with long-standing obesity has been prescribed phentermine/topiramate-ER. What statement by the client suggests that further health education is necessary?

Correct answer: A

Rationale: Choice A suggests the need for further health education as the client expresses a reluctance to exercise or change dietary habits, indicating a lack of understanding about the importance of lifestyle modifications in conjunction with medication for effective weight management. It is important for the client to comprehend that a holistic approach, including lifestyle changes, is crucial for successful obesity treatment and long-term health benefits.

3. A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT)/INR. Warfarin affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time (PT) and international normalized ratio (INR) is crucial to assess the effectiveness and safety of warfarin therapy. These tests help determine if the patient is within the desired anticoagulation range to prevent either clotting issues or excessive bleeding.

4. A client with liver cirrhosis is being educated about managing their condition. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Clients with liver cirrhosis should avoid acetaminophen because it can cause further liver damage. Acetaminophen is metabolized in the liver, and in individuals with liver disease, it can lead to liver toxicity. Therefore, clients with liver cirrhosis should use alternative pain medications that do not affect the liver, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids as prescribed by their healthcare provider. Choices A, B, and D are correct statements for managing liver cirrhosis. Avoiding alcohol helps prevent further liver damage, limiting salt intake helps manage fluid retention and complications like ascites, and eating a balanced diet supports overall health and helps prevent malnutrition.

5. When implementing patient teaching for a patient admitted with hyperglycemia and newly diagnosed diabetes mellitus scheduled for discharge the second day after admission, what is the priority action for the nurse?

Correct answer: C

Rationale: The priority action for the nurse when time is limited is to focus on essential teaching. In this scenario, the patient should be educated on how to self-monitor glucose levels and administer medications to control glucose levels. This empowers the patient with immediate skills for managing their condition. Instructing about the increased risk of cardiovascular disease (choice A) is important but not as urgent as teaching self-monitoring and medication administration. Providing detailed information about dietary glucose control (choice B) can be beneficial but is secondary to ensuring the patient can monitor and manage their glucose levels. Teaching about the effects of exercise (choice D) is relevant but not as critical as immediate self-monitoring and medication administration education.

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