Nokea
The nurse anticipates the client will likely require-------as evidenced by the client’s---------
- A. temperature
- B. stool test results
- C. respiratory rate
- D. an endoscopy
- E. an antifungal prescription
- F. oxygen via nonrebreather mask
Correct Answer: B,D
Rationale: The correct answers are B (stool test results) and D (an endoscopy). The nurse anticipates the client will likely require a stool test based on gastrointestinal symptoms, such as abdominal pain or blood in stool. Stool test results can help diagnose gastrointestinal issues. Additionally, the nurse may anticipate the need for an endoscopy to further investigate gastrointestinal symptoms, like persistent reflux or difficulty swallowing. Choices A, C, E, and F are less likely as they are not directly related to gastrointestinal issues. Choice E (antifungal prescription) may be relevant in case of fungal infection, but gastrointestinal symptoms would not typically prompt this. Choice F (oxygen via nonrebreather mask) is more related to respiratory issues.
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For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
- A. Encourage the client to make his own list after he returns to his home
- B. Include any adverse effects of the medications the client might develop
- C. Exclude nutritional supplements from the list of medications the client reports
- D. Compare new prescriptions with the fist of medications the client reports,
Correct Answer: D
Rationale: Comparing prescriptions prevents duplication and interactions.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it stenile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (B) can introduce contaminants to the field, holding the bottle in the center (C) does not prevent contamination, and the orientation of the label (D) does not affect sterility.
Which of the following information should the nurse include?
- A. Information Technology will install a firewall to secure client information
- B. You will be asked to change your password once per year.
- C. Documentation of sensitive material is performed by the charge nurse.
- D. You will be given access to the medical records of every client in the facility.
Correct Answer: A
Rationale: Firewalls help protect sensitive client information in electronic health records.
Complete the following sentence by using the lists of options.The client is at highest risk for developing---- as evidenced by the client's-------
- A. endometritis
- B. mastitis
- C. perineal hematoma
- D. large for gestational age newborn
- E. group B streptococcus
- F. tracked nipple
Correct Answer: B,F
Rationale: Cracked nipples increase the risk of mastitis, especially in breastfeeding mothers.