Nokea
A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?
- A. Keep the client NPO for 12 hours after the procedure
- B. Inform the client that general anesthesia will be administered
- C. Assess the site for bleeding or hematoma once per shift
- D. Instruct the client that he might be asked to cough and breathe deeply during the procedure
Correct Answer: D
Rationale: During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.
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The nurse is developing a care plan for a client with hepatitis A. The nurse knows that the primary routes of transmission of this hepatitis virus are which of the following? Select all that apply.
- A. sputum
- B. blood
- C. feces
- D. contaminated food
Correct Answer: C,D
Rationale: Hepatitis A is transmitted primarily via the fecal-oral route, through contaminated food or water (D) and feces (C).
A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?
- A. Clients have the right to view their medical records but may not copy any of the information contained in the records.
- B. Clients may be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance.
- C. Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan.
- D. It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information.
Correct Answer: C
Rationale: The Patient’s Bill of Rights includes the right to a fair review of claims against healthcare providers. Other options are incorrect or misrepresent client rights.
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
- A. Living in an area where the soil is depleted of iodine
- B. Eating foods that decrease the thyroxine level
- C. Using aluminum cookware to prepare the family's meals
- D. Taking medications that decrease the thyroxine level
Correct Answer: A
Rationale: Endemic goiter is caused by iodine deficiency, often due to low iodine levels in soil, leading to inadequate thyroid hormone production.
A client who was prescribed increasing dosages of baclofen to relieve muscle spasms should have taken 80 mg daily in 4 divided doses but misunderstood and took 80 mg four times a day, resulting in an overdose and pronounced CNS depression. Which of the following treatments does the nurse anticipate?
- A. Administration of naloxone.
- B. Administration of atropine.
- C. Supportive care only.
- D. Administration of flumazenil.
Correct Answer: C
Rationale: Baclofen overdose causes CNS depression, treated with supportive care (C) like ventilation and monitoring. Naloxone (A), atropine (B), and flumazenil (D) are not antidotes for baclofen.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.