Nokea
A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction?
- A. Maintain a consistent intake of green leafy foods
- B. Report any nose or gum bleeds
- C. Take Tylenol for minor pains
- D. Use a soft toothbrush
Correct Answer: B
Rationale: Report any nose or gum bleeds. The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.
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The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?
- A. peak expiratory flow rate reading
- B. arterial blood gas analysis
- C. pulse oximetry reading
- D. CT scan of the chest
Correct Answer: B
Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
- A. Perform fundal massage
- B. Document the exact time of events
- C. Flex the client's legs back against the abdomen
- D. Request immediate assistance from other nurses
- E. Apply downward pressure above the client's symphysis pubis
Correct Answer: B,C,D,E
Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.
An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.