Nokea
A client is diagnosed with pernicious anemia. The nurse reviews the client's health history for disorders involving which organ responsible for vitamin B12 absorption?
- A. Liver
- B. Ileum
- C. Kidney
- D. Hepatobiliary
Correct Answer: B
Rationale: Pernicious anemia can occur in a client who has a disease involving the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor. The liver and the kidney are not related to impaired B12 absorption. Hepatobiliary refers to the liver and gallbladder.
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The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
- A. Fish
- B. Dog
- C. Cat
- D. Bird
Correct Answer: A
Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
Which of the following security concerns is also a sentinel event that must be reported?
- A. A possible vulnerability of the facility's information technology to hacking
- B. The assisted suicide of a client in your facility by the spouse of the client
- C. Vulnerability to computer hacking
- D. Potential information theft
Correct Answer: B
Rationale: The assisted suicide of a client is a sentinel event, as it is an unexpected occurrence involving death, requiring immediate investigation and reporting per The Joint Commission standards.
A nurse is caring for a client with a suspected myocardial infarction. Which of the following laboratory results should the nurse prioritize?
- A. Elevated troponin levels
- B. Decreased hemoglobin
- C. Increased potassium
- D. Elevated white blood cell count
Correct Answer: A
Rationale: Troponin is a specific marker for myocardial damage and is critical in diagnosing myocardial infarction. Other results are less specific to this condition.
Which of these clients is at greatest risk for falls?
- A. A 77 year old female client in a client room that has low glare floors.
- B. An 87 year old female client in a client room that has low glare floors.
- C. A 27 year old sedated male client.
- D. A 37 year old male client with impaired renal perfusion.
Correct Answer: B
Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.
A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is:
- A. Malpractice
- B. Hespondeat superior
- C. Negligent
- D. Tort
Correct Answer: B
Rationale: Respondeat superior is Latin for 'The master is responsible for the acts of his servant'. The nurse, as an employee of the hospital, acted according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence, or tort law. (CN: Management of care; CL: Evaluate)