Nokea
A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.
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The stages of conflict and conflict resolution in the correct sequential order are:
- A. Conceptualization
- B. Frustration
- C. Resolution
- D. Taking action
Correct Answer: B,A,D,C
Rationale: The correct sequence of conflict stages is Frustration (B, emotional response), Conceptualization (A, understanding the conflict), Taking action (D, implementing solutions), and Resolution (C, resolving the conflict).
The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
- A. CQI processes are required by accrediting agencies
- B. The approach to CQI can be retrospective or concurrent
- C. Institutional Review Board (IRB) approval is required
- D. CQI is conducted by people who are not part of the process
- E. The CQI process has a fixed endpoint
Correct Answer: A,B
Rationale: CQI is often required by accrediting agencies and can be retrospective or concurrent. IRB approval is not typically needed, CQI involves unit staff, and it is ongoing without a fixed endpoint.
When performing an assessment on a mother who just delivered a healthy newborn, the nurse should expect to note that the fundus is positioned at which location?
- A. To the right of the abdomen
- B. At the level of the umbilicus
- C. Above the level of the umbilicus
- D. One fingerbreadth above the symphysis pubis
Correct Answer: B
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. A fundus that is not located in the midline may indicate a full bladder. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus need to be expelled by fundal massage.
After your assessment of your client and the need to transfer your client from the bed to the chair, what is the best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client's first transfer out of bed?
- A. Use a slide board.
- B. Use a mechanical lift.
- C. Use a gait belt.
- D. Notify the client's doctor that the client cannot be safely transferred by you.
Correct Answer: B
Rationale: For a paralyzed client requiring assistance, a mechanical lift is the safest transfer method, minimizing risk of injury to both the client and staff.
A client with a diagnosis of polycythemia vera is prescribed hydroxyurea (Hydrea). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bone marrow suppression.
- C. Hyperkalemia.
- D. Weight gain.
Correct Answer: B
Rationale: Hydroxyurea can cause bone marrow suppression, requiring monitoring of blood counts for anemia or leukopenia.