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The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.
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The nurse is caring for a 45-year-old client with atrial fibrillation who has been receiving diltiazem. Which of the following findings would indicate that the medication has been effective?
- A. Blood pressure of 126/78 mm Hg
- B. Client does not have chest pain
- C. Client has not experienced any signs of stroke
- D. Ventricular rate decreased from 158/min to 88/min
Correct Answer: D
Rationale: Diltiazem is used in atrial fibrillation to control ventricular rate. A decrease from 158/min to 88/min indicates effective rate control. Blood pressure, chest pain, and stroke prevention are not primary indicators of diltiazem's efficacy in this context.
Nursing considerations when caring for African-American clients include that:
- A. families are generally distant and unsupportive.
- B. special hair, skin, and nail care might be required.
- C. fad diets are a cultural norm.
- D. clients are generally future-oriented.
Correct Answer: B
Rationale: African-American clients may require specific hair, skin, and nail care due to unique characteristics, like curly hair or skin sensitivity. The other generalizations are inaccurate or stereotypical. Psychosocial Integrity
A man is being discharged following a vasectomy. Which comment by the client indicates a need for more instruction?
- A. I will wear this scrotal support for the next few days.'
- B. I will continue to use a condom for the next two weeks.'
- C. My wife and I have decided that the four children we have are all we want.'
- D. I will keep the area clean and observe for signs of infection.'
Correct Answer: B
Rationale: Condom use is needed for 6-12 weeks post-vasectomy until azoospermia is confirmed, not just 2 weeks. Scrotal support, family planning, and hygiene are appropriate.
The nurse is reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. Which of the following interventions should the nurse include in the plan of care for a preschool-age child? Select all that apply.
- A. Allow the child's parents to stay during the procedure
- B. Emphasize that dressing changes are not punishment for misbehavior
- C. Encourage the child to voice questions and concerns about the procedure
- D. Have the child place bandages on a doll when reinforcing education
- E. Introduce the child to other clients with the same health condition
Correct Answer: A,B,C,D
Rationale: Parental presence provides comfort, clarifying that procedures are not punishment reduces fear, encouraging questions fosters understanding, and bandaging a doll makes the process relatable. Introducing the child to others with the same condition may breach privacy or cause distress.
Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
- A. CVADs are less expensive than a peripheral IV.
- B. Weekly administration is possible.
- C. Chemotherapeutic agents can be caustic to smaller veins.
- D. The client or family can administer the drug at home.
Correct Answer: C
Rationale: Many chemotherapeutic agents are vesicants, damaging smaller peripheral veins. CVADs allow safe administration into larger veins. CVADs are more expensive, dosing varies, and home administration is rare. Pharmacological Therapies