Nokea
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.
You may also like to solve these questions
The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
- A. Emboli formation.
- B. Fluid volume overload.
- C. Red blood cell hemolysis.
- D. Allergic reaction.
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. Pushing with palms when rising from a chair.
- B. Holding packages close to the body.
- C. Sliding objects.
- D. Carrying a laundry basket with clinched fingers and fists.
Correct Answer: D
Rationale: Carrying heavy loads with clinched fingers stresses small joints, increasing pain and deformity risk. The other actions minimize joint strain.
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 1 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.
- A. blood pressure
- B. temperature
- C. pulse and respirations
- D. pulse oximetry
- E. lung sounds
- F. neurological assessment findings
- G. thready peripheral pulses
Correct Answer: A,B,C,F,G
Rationale: Blood pressure (94/57) indicates hypotension, temperature (105°F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion—all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.