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A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.
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A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
A risk management program within a hospital is responsible for all of the following except:
- A. identifying risks.
- B. controlling financial loss due to malpractice claims.
- C. making sure that staff follow their job descriptions.
- D. analyzing risks and trends to guide further interventions or programs.
Correct Answer: C
Rationale: Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff.
A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:
- A. Suggest a script for counseling for the family to the doctor on duty.
- B. Recommend a warm bath for the boy to decrease healing time.
- C. Notify the case manager in the clinic about possible child abuse concerns.
- D. Recommend ROM to the patient's spine to decrease healing time.
Correct Answer: C
Rationale: The patient's safety should have the highest priority.
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
The expectant mother asks the nurse, "With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?" What is the nurse's best response?
- A. "The baby has a plastic bracelet with permanent locks that must be cut for removal."
- B. "If taken from the unit, your baby's security band will set off an alarm and lock exits."
- C. "Your identification number and full name are printed on your baby's identification band."
- D. "An identification band is applied to your infant, and footprints are taken and kept on record."
Correct Answer: C
Rationale: Matching identification numbers and the mother's full name on the infant's band ensures accurate identification, which is the primary method.