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Which is an example of a sentinel event?
- A. The terminally ill client is referred to hospice and dies 3 months later.
- B. A client receives an unordered mammogram which reveals a small cyst.
- C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
- D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.
Correct Answer: D
Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
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A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on a honey-thick diet
- B. Pain felt during a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.
When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
- A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
- B. Risk for injury related to active loss of blood from the vascular space
- C. Deficient knowledge related to the client's lack of understanding of the disease process
- D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct Answer: B
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.
When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?
- A. Allergies to shellfish
- B. Date of last platelet donation
- C. Time of last oral intake
- D. Blood type
Correct Answer: B
Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.
The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:
- A. Remove air from the pleural space
- B. Create access for irrigating the chest cavity
- C. Evacuate secretions from the bronchioles and alveoli
- D. Drain blood and fluid from the pleural space
Correct Answer: A
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.