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1. A healthcare professional is caring for a client with coronary artery disease (CAD) who is prescribed aspirin. Which of the following findings should the healthcare professional report to the provider?
- A. A history of gastrointestinal bleeding
- B. A history of hypertension
- C. A platelet count of 180,000/mm³
- D. A prothrombin time (PT) of 12 seconds
Correct answer: A
Rationale: The correct answer is A: A history of gastrointestinal bleeding. Patients with a history of gastrointestinal bleeding are at increased risk of complications when taking aspirin due to its effects on platelet function and the gastrointestinal tract. Reporting this finding to the provider is crucial to ensure patient safety. Choices B, C, and D are not directly related to the increased risk associated with aspirin use in patients with a history of gastrointestinal bleeding, making them less relevant in this scenario. While monitoring platelet count and PT are important in patients taking aspirin, a history of gastrointestinal bleeding takes precedence as it directly impacts the safety and effectiveness of aspirin therapy in this client.
2. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?
- A. Threatening to withhold food from a client
- B. Informing a client about an upcoming procedure
- C. Informing a client about risks of refusing treatment
- D. Informing a client that they will be given an injection against their will
Correct answer: D
Rationale: The correct answer is D because assault involves threatening a client with harm or unwanted procedures. In this scenario, informing a client that they will be given an injection against their will constitutes assault. Choices A, B, and C do not involve the element of threatening harm or unwanted procedures, making them incorrect. Choice A is more related to neglect, choice B is related to informing the client about a procedure, and choice C is related to informed consent and refusal of treatment, not assault.
3. What lifestyle change should be emphasized for a client with hypertension?
- A. Increase intake of dairy products
- B. Reduce caffeine and sodium intake
- C. Eat carbohydrate-rich meals
- D. Limit intake of leafy green vegetables
Correct answer: B
Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.
4. A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?
- A. Fatigue
- B. Constipation
- C. Hair loss
- D. Weight gain
Correct answer: A
Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.
5. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?
- A. Inspection, Palpation, Percussion, Auscultation
- B. Palpation, Inspection, Observation, Auscultation
- C. Percussion, Inspection, Auscultation, Palpation
- D. Inspection, Percussion, Auscultation, Palpation
Correct answer: A
Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.
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