Nokea
During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?
- A. Dirty carpets requiring vacuuming
- B. Expired food found in the refrigerator
- C. Outdated medications stored in the kitchen
- D. Presence of multiple cats in the home
Correct Answer: B
Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.
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A student asks the faculty to explain best practices when communicating with a person from the LGBTQ community. What answer by the faculty is most accurate?
- A. Avoid embarrassing the individual by asking questions.
- B. Don't make assumptions about their health needs.
- C. Most LGBTQ individuals do not want to share information.
- D. No differences exist in communicating with this group.
Correct Answer: B
Rationale: The correct answer is B: Don't make assumptions about their health needs.
Rationale:
1. LGBTQ individuals have diverse health needs.
2. Making assumptions can lead to inappropriate or inadequate care.
3. By not assuming, you show respect and promote open communication.
4. This approach fosters trust and ensures individualized care.
Other choices:
A: Avoiding questions can hinder understanding and communication.
C: Generalizing that most LGBTQ individuals do not share information is inaccurate.
D: Differences exist in the LGBTQ community that should be acknowledged for effective communication.
The most common, preventable complication of abdominal surgery is
- A. atelectasis.
- B. fluid and electrolyte imbalance.
- C. thrombophlebitis.
- D. urinary retention.
Correct Answer: D
Rationale: Urinary retention is a common issue post-abdominal surgery due to anesthesia effects and immobility.
Steve has developed pneumonia following intrathoracic surgery performed last week. He has no comorbidities and the hospital does not have a high rate of MRSA infections. Treatment for postoperative pneumonia would most likely include a:
- A. Cephalosporin, such as cefazolin.
- B. Penicillin, such as amoxicillin.
- C. Fluoroquinolone, such as levofloxacin.
- D. Tetracycline, such as doxycycline.
Correct Answer: C
Rationale: Fluoroquinolones like levofloxacin are effective against a broad spectrum of pathogens and are often used to treat postoperative pneumonia, especially in cases without MRSA concerns.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.