Nokea
The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
- A. privacy
- B. Patient's Bill of Rights
- C. continuity of care
- D. case management
Correct Answer: C
Rationale: Proper handoffs ensure continuity of care by transferring critical information accurately between care teams.
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The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
- A. Tell the client to avoid a tub bath for 48 hours
- B. Tell the client to expect clay-colored stools
- C. Tell the client that she can expect lower abdominal pain for the next week
- D. Tell the client to report pain in the back or shoulders
Correct Answer: D
Rationale: Pain in the back or shoulders post-laparoscopic cholecystectomy may indicate referred pain from residual CO2 or complications, requiring prompt reporting.
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
- A. Diabetes
- B. Prinzmetal's angina
- C. Cancer
- D. Cluster headaches
Correct Answer: B
Rationale: Prinzmetal's angina is a contraindication for sumatriptan due to the risk of coronary vasospasm, and this should be reported to the doctor.
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.
A nurse performing a newborn assessment would expect what respiratory rate and heart rate as a normal finding?
- A. RR 15 breaths/minute, HR 72 beats/minute
- B. RR 35 breaths/minute, HR 96 beats/minute
- C. RR 46 breaths/minute, HR 153 beats/minute
- D. RR 68 breaths/minute, HR 137 beats/minute
Correct Answer: C
Rationale: Newborns have a respiratory rate of 30-60 breaths/min and heart rate of 120-160 beats/min. Option C (RR 46, HR 153) is within normal ranges.
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
- A. I do not need to limit my time in public places.'
- B. I may share food from serving dishes with others at a restaurant.'
- C. I may use public restrooms.'
- D. I may donate blood.'
Correct Answer: D
Rationale: AIDS patients cannot donate blood due to HIV transmission risk. Public activities and restrooms pose minimal risk, and sharing serving dishes is safe if not directly contaminated.