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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 healthcare professional is preparing to administer a blood transfusion. What is the first step?
- A. Administer the blood through an IV push
- B. Verify that the client's blood type matches the blood product
- C. Ensure the client has eaten before the transfusion
- D. Administer a diuretic before starting the transfusion
Correct answer: B
Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.
3. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. Experiencing delusions.
- B. Male gender.
- C. Previous violent behavior.
- D. A history of being in prison.
Correct answer: C
Rationale: The correct answer is C: Previous violent behavior. This is considered the best predictor of future violent actions as individuals who have a history of violent behavior are more likely to engage in violent acts again. Option A, experiencing delusions, although it can impact behavior, is not as strong of a predictor as past violent behavior. Option B, male gender, is a demographic factor but not as specific or predictive as a history of violence. Option D, a history of being in prison, may indicate past behavior but is not directly linked to future violent actions as a known history of violence.
4. A client is scheduled for a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?
- A. Ensure the client is fasting before the test
- B. Provide a warm blanket for the client
- C. Apply cold compresses to the client's chest
- D. Instruct the client to remain still
Correct answer: D
Rationale: During a 12-lead ECG, the client needs to remain still to obtain accurate readings. Therefore, instructing the client to remain still is essential. Choices A, B, and C are incorrect because fasting is not necessary for an ECG, providing a warm blanket is not a standard procedure, and applying cold compresses may interfere with the ECG results.
5. What is the priority intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct answer: D
Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.
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