The nurse is caring for a client with advanced heart failure and cardiomyopathy. The nurse understands that involving nursing, nutritional services, cardiology, and pharmacy in the client's care team is an example of which approach?
- A. peer review
- B. team nursing
- C. multidisciplinary
- D. community nursing
Correct Answer: C
Rationale: A multidisciplinary approach integrates multiple specialties for comprehensive care, as seen with nursing, nutrition, cardiology, and pharmacy.
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The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
- A. Withholding oral intake after midnight
- B. Telling the client that no special preparation is needed
- C. Explaining that a small dose of radioactive isotope will be used
- D. Giving an oral suspension of glucose 1 hour before the test
Correct Answer: B
Rationale: A blood test for H. pylori requires no special preparation, such as fasting or administration of substances.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain a culture of:
- A. Blood
- B. Nasopharyngeal secretions
- C. Stool
- D. Genital secretions
Correct Answer: D
Rationale: Gonorrhea is diagnosed by culturing genital secretions.
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?
- A. Post-coital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Post-coital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor friability. The other symptoms are less specific or related to advanced disease.
A client is to be discharged on warfarin (Coumadin®) therapy, and the nurse is teaching the client about the medication. Which of the following statements by the client indicates that the client's education has been effective? Select all that apply.
- A. I should use a soft toothbrush.
- B. My stools will routinely be black.
- C. Swimming is a good choice for exercise.
- D. I should wear a Medical Alert bracelet.
- E. I should avoid all green, leafy vegetables.
Correct Answer: A,C,D
Rationale: Soft toothbrush (A), swimming (C), and Medical Alert bracelet (D) reduce bleeding risk and ensure safety. Black stools (B) indicate bleeding, and avoiding all leafy greens (E) is excessive.
A client with cancer is to undergo a bone scan. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield
Correct Answer: B
Rationale: Voiding immediately before a bone scan ensures the bladder is empty, reducing interference with pelvic imaging and improving the accuracy of the scan.
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