Nokea
Which of the following is an effective security plan that you may most likely want to consider for implementation within your facility?
- A. Training all nurses to serve as a part of a security response team
- B. Training all clerical staff to be a part of a security response team
- C. The restriction of visitors in a special care area
- D. Bar coded client identification bands to insure proper identification
Correct Answer: C,D
Rationale: Restricting visitors in special care areas and using bar-coded client identification bands are effective security measures to enhance safety and protect client identity, respectively.
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The nurse is teaching a client with a new diagnosis of gout about dietary management. Which of the following foods should the client include?
- A. Cherries.
- B. Red meat.
- C. Shellfish.
- D. Organ meats.
Correct Answer: A
Rationale: Cherries reduce uric acid levels and inflammation in gout.
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
- A. Assess the patency of the Foley catheter
- B. Assess urine for excessive bleeding
- C. Assess urine for excessive bleeding
- D. Obtain a urine specimen for culture
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
- A. The client's cardiovascular status.
- B. The client's emotional state.
- C. The type of sedation used.
- D. Pacemaker rate, type, and settings.
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
A client with a history of cirrhosis is admitted with esophageal varices. The nurse should monitor the client for which of the following complications?
- A. Hematemesis.
- B. Hypotension.
- C. Fever.
- D. Constipation.
Correct Answer: A, B
Rationale: Esophageal varices can rupture, causing hematemesis and hypotension.
The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
- A. Check that the dose is appropriate for the child's weight.
- B. Note that the onset of the medication will be immediate.
- C. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
- D. Monitor partial thromboplastin time (PTT).
- E. Discontinue the penicillin until the PTT is at a therapeutic level.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.