Nokea
The healthcare provider is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct Answer: B
Rationale: The correct answer is taking anticoagulants for the past year. Anticoagulants increase the risk of bleeding during surgery, which can lead to complications. It is crucial for the healthcare provider to be aware of this medication. While clients taking birth control pills (option A) may be more prone to developing blood clots, these issues typically arise after surgery. Clients who recently completed antibiotic therapy (option C) or have taken laxatives PRN for the last 6 months (option D) are at lower risk compared to those taking anticoagulants (option B) during surgery.
You may also like to solve these questions
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretive Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose × Volume on hand) / Dose on hand). In this case, it would be (4 mg × 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
- A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
- B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
- C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
- D. Compare the current reading with the client's previously documented blood pressure readings.
Correct Answer: D
Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
- B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
- C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct Answer: C
Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith from malpractice claims, regardless of the client outcome. In this scenario, the nurse stopped at the scene voluntarily to render aid, which is protected under the Good Samaritan Act. This law shields individuals from legal liability when providing emergency care in good faith and without expectation of compensation. The Patient's Bill of Rights does protect clients, but in this case, the nurse's actions were protected by the Good Samaritan Act. Additionally, the state Board of Nursing would not likely revoke the nurse's license unless there was evidence of actions taken in bad faith or unreasonable care. The client would not win the lawsuit as the essential elements of malpractice, including duty, breach, causation, and damages, were not met in this situation.