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A 46 year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The patient should keep the leg straight for at least 4 hours.
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Which of the following statements indicates adequate dietary understanding in a client with constipation?
- A. I should decrease my intake of fluids.
- B. I should decrease my level of activity.
- C. I should increase my intake of apples.
- D. I should increase my intake of milk.
Correct Answer: C
Rationale: Apples are a source of high fiber, which decreases constipation. A constipated client needs to increase fluids and activity level. Milk is not a high-fiber food.
The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
- A. Place the client in the waiting room until an available cubicle is open
- B. Seclude the client from other clients and visitors
- C. Perform no intervention because it might not be necessary until tests confirm a disease
- D. Don gown, gloves, and mask immediately
Correct Answer: B
Rationale: Symptoms suggestive of tuberculosis require immediate seclusion to prevent transmission, with caregivers using respirator masks.
Which medication might the physician order if the client expresses discomfort with being in the enclosed space of a CT scanner?
- A. Valium (diazepam)
- B. Clozaril (clozapine)
- C. Catapress (clonidine)
- D. Lasix (furosemide)
Correct Answer: A
Rationale: Valium, a sedative, is appropriate to reduce anxiety and discomfort in a confined CT scanner, unlike the other medications, which have different indications.
Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
- A. outbreak of Asian flu.
- B. Chemical exposure.
- C. bacterial pneumonia.
- D. allergic reaction.
Correct Answer: B
Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure.
A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
- A. positive
- B. false positive
- C. negative
- D. false negative
Correct Answer: B
Rationale: A false positive occurs when a test incorrectly indicates a disease is present, potentially leading to unnecessary treatment or anxiety.