Nokea
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
- A. Avoid driving until seizures are controlled.
- B. Take baths instead of showers.
- C. Use a microwave instead of a stove.
- D. Sleep on a low bed with side rails.
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
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The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bleeding.
- B. Encourage deep breathing exercises.
- C. Administer oral pain medications.
- D. Restrict all visitors.
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.
An 80-year-old client with severe kidney damage is placed on life support and dialysis. Care decisions are being made by his wife, who is showing signs of early Alzheimer's disease. The client's daughter arrives from out of town with a copy of the client's living will, which states that the client did not want to be on life support. The nurse should:
- A. Immediately inform the physician about the living will.
- B. Suggest to the daughter that she discuss her father's wishes with her mother.
- C. Prepare to remove the client from life support.
- D. Make a copy of the living will and give it to the client's wife.
Correct Answer: A
Rationale: Informing the physician about the living will ensures that the client's wishes are addressed promptly.
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.