Nokea
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.
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The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with
- A. Infectious mononucleosis.
- B. Mycoplasma pneumonia.
- C. Gastroenteritis (rotavirus).
- D. Mumps (infectious parotitis).
Correct Answer: A
Rationale: HIV is not airborne or droplet-transmitted, so rooming with a client with mononucleosis (non-respiratory transmission) is safe. Mycoplasma, rotavirus, and mumps require specific precautions.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?
- A. You will need to lay flat immediately after this procedure.
- B. A heating pad will be applied to the affected area for pain relief.
- C. Before you eat, your gag reflex will need to return.
- D. You can resume your regular activities and diet right after the procedure.
Correct Answer: A
Rationale: Lying flat post-kidney biopsy prevents bleeding complications. Heating pads are not standard, gag reflex is irrelevant, and immediate activity resumption is unsafe.
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
- A. Perform range of motion with the client's left leg.
- B. Obtain the client's temperature.
- C. Assess the client for pain.
- D. Administer prescribed oxycodone-acetaminophen.
Correct Answer: C
Rationale: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.