A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

"You will not become fatigued when you use assistive devices."

"Plan to hire a home care aid to perform all of your ADLs."

"Install grab bars in your shower to assist with your balance."

"Place a towel in the shower to prevent slipping

Answer and Explanation

The Correct Answer is C

"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.

Choice B Reason:

"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.

While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.

Choice C Reason:

"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.

Choice D Reason:

"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.

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Correct Answer is C

Explanation

Choice A Reason:
Digoxin is a cardiac medication used to treat heart conditions such as heart failure and certain arrhythmias. There's no direct chemical relationship between digoxin and sulfa compounds. Generally, digoxin does not contain sulfa components, so it's less likely to cause an allergic reaction in individuals with sulfa allergies. This medication does not typically require clarification for someone with a sulfa allergy.

Choice B Reason:
Prednisone is a corticosteroid used to treat a variety of conditions, including inflammation, allergies, and autoimmune disorders. It does not contain sulfonamide groups in its structure. As a corticosteroid, prednisone is distinct from sulfonamide drugs and is generally considered safe for individuals with sulfa allergies. There is typically no need to clarify this medication for a sulfa-allergic client.

Choice C Reason:
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the sulfonamide class. While it is not the same as sulfonamide antibiotics, it contains a sulfonamide moiety in its chemical structure. There's a possibility of cross-reactivity or allergic reactions in individuals with sulfa allergies due to the structural similarity, making it essential to clarify this prescription for someone with a sulfa allergy.

Choice D Reason:
Atorvastatin is a statin medication used to lower cholesterol levels. It does not contain a sulfonamide group in its structure. Statins belong to a different drug class and do not typically pose a risk of cross-reactivity in individuals with sulfa allergies. Therefore, atorvastatin is generally considered safe and does not usually require clarification for a sulfa-allergic client.

A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. B. Check the medication administration record to verify the client's allergies. C. Slowly inject the medication into the site without aspirating. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. E. Ensure an air bubble is present in the prefilled enoxaparin syringe.

Correct Answer is B, E, A, D, C

Explanation

B. Check the medication administration record to verify the client's allergies. Before preparing or administering any medication, the nurse must verify the client’s medication order and allergies to ensure safety. E. Ensure an air bubble is present in the prefilled enoxaparin syringe. The prefilled syringe contains an air bubble that should remain to ensure the entire dose is administered and to prevent medication from tracking back through the tissue. A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. Enoxaparin should be administered in the subcutaneous tissue of the abdomen, avoiding areas near the umbilicus to reduce the risk of irritation and bruising. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. Pinching the skin ensures the medication is delivered into the subcutaneous tissue, and injecting at a 90° angle minimizes pain and ensures proper technique. C. Slowly inject the medication into the site without aspirating. Aspiration is not necessary for subcutaneous injections. Slowly injecting reduces discomfort and ensures proper absorption.

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A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a sulfa allergy. Which of the following prescriptions should the nurse clarify with the provider?

Correct Answer is C

Explanation

A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, E, A, D, C

Explanation

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