Nokea
Which of the following is NOT a procedure to reduce risks associated with invasive surgeries?
- A. Surgical site marking
- B. A time out
- C. Medication reconciliation
- D. A neutral zone for sharps
Correct Answer: C
Rationale: Medication reconciliation ensures accurate medication lists but is not specific to reducing surgical risks, unlike site marking, time out, and neutral zones for sharps.
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A client with a diagnosis of gout is prescribed naproxen. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking naproxen with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
Which statement about targeted assessments is accurate?
- A. The need for a targeted assessment is based on the application of the nurse's knowledge of pathophysiology and the presenting symptoms.
- B. The need for a targeted assessment is based on the application of the nurse's knowledge of developmental needs and developmental delays.
- C. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
- D. Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment.
Correct Answer: A
Rationale: Targeted assessments focus on specific health issues based on the nurse's knowledge of pathophysiology and the patient's presenting symptoms, allowing for a focused evaluation rather than a comprehensive one.
A female client is treated for trichomoniasis with metronidazole (Flagyl). The nurse instructs the client that:
- A. The medication should not alter the color of the urine.
- B. She should discontinue oral contraceptive use during this treatment.
- C. She should avoid alcohol during treatment and for 24 hours after completion of the drug.
- D. Her partner does not need treatment.
Correct Answer: C
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoiding alcohol during and 24 hours after treatment is critical.