Nokea
Which of the following herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.
- A. Black cohosh
- B. Garlic
- C. Ginger
- D. Ginkgo biloba
- E. Hawthorn
Correct Answer: B,C,D
Rationale: Garlic (B), ginger (C), and ginkgo biloba (D) have antiplatelet effects, increasing bleeding risk. Black cohosh (A) and hawthorn (E) do not significantly affect bleeding.
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A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
- A. Expressing feelings of low self-worth
- B. Discussing remorse and guilt for actions
- C. Displaying dependence on others
- D. Expressing anger toward others
Correct Answer: A
Rationale: Clients with severe depression and suicidal ideation often struggle to express feelings of low self-worth , which contributes to their emotional withdrawal. Discussing remorse or dependence may be present but is less central. Expressing anger is more typical in other conditions like bipolar disorder.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
The nurse is preparing to give an adult a subcutaneous injection of heparin. What should the nurse check prior to giving the medication?
- A. International normalized ratio (INR)
- B. Bleeding time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: D
Rationale: Partial thromboplastin time (PTT) monitors heparin's anticoagulant effect, ensuring safe administration by assessing bleeding risk.
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown below. The nurse should recognize that the client is experiencing
- A. atrial flutter
- B. sinus bradycardia
- C. normal sinus rhythm
- D. premature atrial contractions
Correct Answer: C
Rationale: Without the ECG strip, normal sinus rhythm (C) is assumed for a stable client, characterized by regular P waves, QRS complexes, and a rate of 60-100 bpm. Other options indicate abnormal rhythms.
A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that:
- A. Toddlers often misbehave to get the attention of adults.
- B. Toddlers are able to use thought processes to experience events and reactions.
- C. Negative actions that are not immediately punished will be repeated.
- D. Manipulation of objects in their environment enables the toddler to learn about spatial relationships.
Correct Answer: D
Rationale: Toddlers explore spatial relationships through actions like shaking a cup, not necessarily to misbehave. Attention-seeking or punishment is less relevant.