A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

a. "All preoperative clients get this medication."
b. "It helps prevent ulcers from the stress of the surgery."
c. "Since you don't have ulcers, I will have to ask."
d. "The physician prescribed this medication for you."


ANS: B
Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.

Nursing

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The nurse is alert for a serious condition called ___________ that results from pathogens being introduced into the blood stream

ANS:

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A student identifies Fatigue as a health problem and nursing diagnosis for a patient receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this patient problem?

A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you; do you agree?"

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A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions?

a. Flea bites and lice infestation b. Left at a grocery store c. Refuses to take a bath d. Cuts and bruises

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After the patient returns from surgery, you should take the vital signs

A) immediately, then every 5 minutes thereafter. B) immediately, then every 15 minutes for an hour or until stable. C) immediately, then every 30 minutes for 2 hours. D) hourly for the remainder of the shift.

Nursing