Nokea
The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which of the following in the report? Select all that apply.
- A. Vehicle/s description.
- B. Current location of parties involved.
- C. Names and phone numbers of parties involved.
- D. Relationship to hospitalized client.
- E. Tone of voice of each party involved.
Correct Answer: A,B
Rationale: Reporting suspicious activity should include objective details like vehicle description and current location to aid security response. Names, relationships, and tone are less critical unless directly relevant.
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For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
The client with Addison's disease is taking glucocorticoids. Which of the following statements indicates that the client understands how to take the medication?
- A. Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.'
- B. My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day.'
- C. Glucocorticoids are cumulative, so I will take a dose every third day.'
- D. I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.'
Correct Answer: A
Rationale: Glucocorticoid needs vary with stress, requiring dose adjustments in Addison's disease to prevent adrenal crisis.
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?
- A. Sit upright for 30 minutes after meals.
- B. Drink liquids with meals, avoiding caffeine.
- C. Avoid milk and other dairy products.
- D. Decrease the carbohydrate content of meals.
Correct Answer: D
Rationale: Decreasing carbohydrate content helps slow gastric emptying, reducing the risk of dumping syndrome. Sitting upright is helpful but less specific, and drinking liquids with meals can worsen symptoms.
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
- A. Send freshly-collected urine samples to the laboratory.
- B. Return the remainder of the blood component unit to the blood bank.
- C. Return the intravenous administration set to the blood bank.
- D. Alert Risk Management about the incident.
- E. Report the incident to the Infection Control Manager.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.