Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
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Which of the following food choices should the nurse include on the client's food tray?
- A. Bacon and cheese quiche with milk
- B. Scrambled eggs and toast with milk
- C. Shrimp salad and tomato soup with milk
- D. Ham sandwich with milk
Correct Answer: B
Rationale: Kosher diets exclude pork and shellfish.
Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
Select the 5 findings the nurse should plan to include in the report.
- A. Client's report of lack of food in home
- B. ECG results
- C. Numerous bruises in various stages of healing
- D. Client's avoidance of eye contact
- E. Client's report of lack of access to bank accounts
- F. Client’s report of weight loss
Correct Answer: A,C,D,E,F
Rationale: These findings highlight potential abuse and neglect indicators.
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.