Nokea
The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?
- A. Thick, tenacious pulmonary secretions
- B. Low-molecular-weight heparin doses
- C. SCDs wrapped around the legs
- D. Elastic stockings (TED hose)
Correct Answer: B
Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.
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A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?
- A. Ask the client why she has changed her mind
- B. Proceed with the surgery
- C. Notify the surgeon immediately
- D. Document the client's decision
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to ask the client why she has changed her mind. By understanding the client's reasons for refusal, the nurse can address any concerns, provide further information, and ensure that the client's decision is respected. Proceeding with the surgery without clarifying the client's decision or notifying the surgeon immediately would not be appropriate. Documenting the client's decision is important, but it should be done after understanding the rationale behind the decision.
The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.
A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?
- A. Plan to assign the client a different nurse each shift
- B. Limit the number of interdisciplinary team members involved in managing the client's care
- C. Request that the client complete a satisfaction survey at discharge
- D. Start discharge planning on the day of admission
Correct Answer: D
Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.
A client with chronic kidney disease has been prescribed a low-protein diet. Which food should the healthcare provider advise the client to limit?
- A. Chicken breast
- B. Apple
- C. Rice
- D. Banana
Correct Answer: A
Rationale: The correct answer is A: Chicken breast. In chronic kidney disease, a low-protein diet is often recommended to reduce the workload on the kidneys. Chicken breast is a high-protein food that should be limited in such diets to help manage the progression of kidney disease. Choices B, C, and D are low in protein and are generally suitable for individuals following a low-protein diet. Apples, rice, and bananas can be included in moderation as part of a balanced diet for individuals with chronic kidney disease.
The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?
- A. Morning stiffness
- B. Joint deformities
- C. Weight loss
- D. Fever
Correct Answer: D
Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.