Nokea
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
- A. 1 year
- B. 5 years
- C. 10 years
- D. The rest of his life
Correct Answer: D
Rationale: Lifelong immunosuppression is required post-transplant to prevent organ rejection.
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The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.
The nurse is aware that a common mode of transmission of clostridium difficile is:
- A. Use of unsterile surgical equipment
- B. Contamination with sputum
- C. Through the urinary catheter
- D. Contamination with stool
Correct Answer: D
Rationale: C. difficile is transmitted via fecal-oral route through contaminated stool.
Which person is at greatest risk for developing Lyme's disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent exposure to tick-infested outdoor environments, where the disease is transmitted.
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
- A. chloride 167 mEq/L
- B. calcium 9.3 mg/dL
- C. phosphate 3.8 mg/dL
- D. sodium 141 mEq/L
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
The nurse is caring for a client admitted to ICU following a heart attack. The nurse notes on the chart that the client has named his spouse to make decisions regarding his care if he is unable to speak for himself. What is the name of the document the client has signed? Fill in the blank.
- A. Living Will
- B. Do Not Resuscitate Order
- C. Durable Power of Attorney for Healthcare
- D. Advance Directive
Correct Answer: C
Rationale: The document is a **Durable Power of Attorney for Healthcare** or **Healthcare Proxy**, designating the spouse as the decision-maker.