Nokea
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
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A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
- A. Excessive alcohol use.
- B. Gallstones.
- C. Abdominal trauma.
- D. Hypertension.
- E. Hyperlipidemia with excessive triglycerides.
- F. Hypothyroidism.
Correct Answer: A,B,C,E
Rationale: Excessive alcohol use, gallstones, abdominal trauma, and hyperlipidemia with high triglycerides are established risk factors for pancreatitis, as they can disrupt塌 or obstruct pancreatic ducts or cause inflammation.
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.
The nurse is planning a program about women's health and cancer prevention for a community health fair. The nurse should include information about? Select all that apply.
- A. Regular self-exams of the breast and vulva are important self-care activities.
- B. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium.
- C. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer.
- D. Smoking cessation reduces the risk of cervical cancer.
- E. There is limited evidence that cancer in women is inherited.
Correct Answer: A,B,C
Rationale: Self-exams, removal of precancerous lesions, and HPV vaccination are key prevention strategies. Smoking cessation reduces lung cancer risk, not cervical. Some cancers have genetic links.
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
- A. Tell the client to wait another day to see if other symptoms of the flu appear.
- B. Advise the client to take over-the-counter medication for the flu.
- C. Discuss the importance of maintaining an adequate fluid intake.
- D. Report the client's symptoms to the physician after taking the client's temperature.
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
- A. I should position the baby the same way for each feeding.'
- B. I should make sure the baby grasps the entire areola and nipple.'
- C. I should air dry my breasts and nipples for 10 to 15 minutes after the feeding.'
- D. I shouldn't use a hand breast pump if my nipples get sore.'
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.