Nokea
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.
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The nursing staff has a normal nurse-to-client ratio of three clients per nurse on the floor. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?
- A. Nurse Christine should offer to give medications to nurse Ann's other two clients.
- B. Nurse Christine should inform their supervisor that assignments may need to be changed.
- C. Nurse Christine should ask the other nurses who might be able to help nurse Ann.
- D. Nurse Ann should try not to burden the other nurses and continue caring for her assigned clients.
Correct Answer: B
Rationale: When there is a change in the client's status, the supervisor should be made aware so that client care assignments can be changed as needed.
All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:
- A. monitoring intravenous infusion.
- B. assisting a client to the bathroom.
- C. offering fluid intake every 1-2 hours.
- D. monitoring/recording the amount of fluid taken.
Correct Answer: A
Rationale: Monitoring an intravenous infusion must be performed by an RN or LPN. Assisting during activity, offering fluids and recording intake are in the job scope of the nursing assistant.
Which of the following is not an advanced directive?
- A. informed consent
- B. living will
- C. durable power of attorney for health care
- D. health care proxy
Correct Answer: A
Rationale: Informed consent is not a type of advanced directive but is a process for obtaining consent to care or treatment.
When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
- A. some members of the Hispanic and Native-American cultures are very open when discussing sexuality
- B. some cultures view the postpartum period as a state of impurity
- C. some women in the African-American culture view childbearing as a validation of their femaleness
- D. some Native-American women believe monthly menstruation maintains physical well-being and harmony
Correct Answer: A
Rationale: Hispanic and Native-American cultures are often reserved about discussing sexuality, unlike the other culturally accurate statements, which inform care planning.
The nurse acts as an advocate for the nursing profession by performing all of the following activities except:
- A. encouraging political involvement by nurses with their legislators.
- B. acting as a first-aid provider for a children's athletic team.
- C. precepting newly licensed nurses in the work situation.
- D. encouraging as many persons to become nurses as possible.
Correct Answer: D
Rationale: The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible, to those making the laws.