Nokea
Which approach is a priority for the nurse who works with clients from many different cultures?
- A. Speak at least 2 other languages of clients in the neighborhood
- B. Learn about the cultures of clients who are most often encountered
- C. Have a list of persons for referral when interaction with these clients occur
- D. Recognize personal attitudes about cultural differences and real or expected biases
Correct Answer: D
Rationale: The nurse must discover personal attitudes, prejudices and biases specific to different cultures. Awareness of these will prevent negative consequences for interactions with clients and families across cultures.
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The nurse is caring for several clients who will be undergoing diagnostic tests. Which client must the nurse ask about allergies to shellfish? An adult who is scheduled for:
- A. an MRI exam.
- B. a CT scan.
- C. an EEG.
- D. a sleep study.
Correct Answer: B
Rationale: Shellfish allergies may indicate iodine sensitivity, critical for contrast dye used in CT scans, unlike MRI, EEG, or sleep studies.
Post-procedure nursing interventions for electroconvulsive therapy include
- A. Applying hard restraints if seizure occurs
- B. Permitting client to sleep for 4 to 6 hours
- C. Remaining with client until oriented
- D. Expecting long-term memory loss
Correct Answer: C
Rationale: Remaining with client until oriented. The client is groggy and confused post-procedure, requiring close monitoring until fully oriented.
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?
- A. increased platelet count
- B. increased fibrinogen
- C. decreased fibrin split products
- D. decreased bleeding
Correct Answer: B
Rationale: Heparin in DIC halts excessive clotting, preserving fibrinogen by preventing its conversion to fibrin. Increased fibrinogen indicates effective therapy. Other options are secondary or less specific indicators. Physiological Adaptation
A patient who has recently experienced a thrombotic CVA will most likely receive which of the following treatments?
- A. Streptokinase
- B. Morphine
- C. Heparin
- D. Coumadin
Correct Answer: C
Rationale: Heparin is used to prevent further clot formation in thrombotic CVA.
A nurse is caring for a patient with a tracheostomy. Which of the following actions should the nurse take to prevent complications?
- A. Suction the tracheostomy every hour
- B. Clean the tracheostomy site with hydrogen peroxide
- C. Keep the tracheostomy cuff inflated at all times
- D. Change the tracheostomy ties daily
Correct Answer: C
Rationale: Keeping the cuff inflated maintains airway patency and prevents aspiration, but pressure must be monitored to avoid tracheal damage. Routine suctioning, hydrogen peroxide, and daily tie changes are not standard.