Nokea
The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
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Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
- A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
- B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
- C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
- D. A young adult in the second day of treatment for an overdose of acetaminophen
Correct Answer: D
Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.
A risk management program within a hospital is responsible for all of the following except:
- A. identifying risks.
- B. controlling financial loss due to malpractice claims.
- C. making sure that staff follow their job descriptions.
- D. analyzing risks and trends to guide further interventions or programs.
Correct Answer: C
Rationale: Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff.
A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.
The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?
- A. Inform the client's assigned nurse that the client is back in his or her room.
- B. Intercept the client and check the client's name band for a room number.
- C. Stop the client and ask for his or her name and the assigned room number.
- D. Ask the nearby UAP to help the client back into the room with the sign posted.
Correct Answer: B
Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.
The expectant mother asks the nurse, "With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?" What is the nurse's best response?
- A. "The baby has a plastic bracelet with permanent locks that must be cut for removal."
- B. "If taken from the unit, your baby's security band will set off an alarm and lock exits."
- C. "Your identification number and full name are printed on your baby's identification band."
- D. "An identification band is applied to your infant, and footprints are taken and kept on record."
Correct Answer: C
Rationale: Matching identification numbers and the mother's full name on the infant's band ensures accurate identification, which is the primary method.