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1. Staff are sometimes injured when a patient or visitor becomes agitated. If a staff member reports an injury, the following actions should take place: (EXCEPT)
- A. Notify security.
- B. Complete an incident report.
- C. Notify the nursing supervisor.
- D. Ensure that staff has been examined.
Correct answer: B
Rationale: When a staff member reports an injury resulting from an agitated patient or visitor, several actions should be taken. These actions include notifying security to ensure safety, notifying the nursing supervisor for appropriate follow-up, and ensuring that the injured staff member has been examined to assess the extent of the injury. Completing an incident report is not the correct action to exclude because documenting the incident is crucial for legal and healthcare purposes. Incident reports provide a detailed account of what occurred, which is essential for investigations, insurance claims, and improving safety protocols. Therefore, all other options are necessary steps to take when a staff member reports an injury, making completing an incident report the correct answer for exclusion.
2. A nurse is planning care for a client who practices Islam and is currently observing dietary restrictions for the month of Ramadan. Which of the following interventions should the nurse include in the plan of care?
- A. Remove beef products from the dietary plan
- B. Facilitate fasting during daylight hours
- C. Serve meat and dairy items separately
- D. Provide a strictly vegetarian diet on Fridays
Correct answer: B
Rationale: Facilitating fasting during daylight hours respects the dietary practices of clients observing Ramadan.
3. A client who is 48 hours postoperative following abdominal surgery is being assessed by a nurse. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. Sanguineous drainage on the surgical dressing
- C. Temperature of 37.5°C (99.5°F)
- D. Serous drainage on the surgical dressing
Correct answer: B
Rationale: Sanguineous drainage from the surgical site 48 hours after surgery could indicate a complication such as hemorrhage or infection and should be reported. Sanguineous drainage is typically seen in the early postoperative period due to the presence of blood. Serous drainage, on the other hand, is normal in the later stages of wound healing. A heart rate of 80/min is within the normal range for an adult. A temperature of 37.5°C (99.5°F) is slightly elevated but not a concerning finding in the absence of other symptoms.
4. A healthcare provider is caring for a group of clients who are not protected against Varicella. The healthcare provider should prepare to administer the Varicella vaccine at this time to which of the following clients?
- A. 24-year-old woman in the third trimester of pregnancy
- B. 12-year-old child who has a severe allergy to neomycin
- C. 2-month-old infant who has no health problems
- D. 32-year-old man who has essential hypertension
Correct answer: D
Rationale: The correct answer is the 32-year-old man who has essential hypertension. Individuals who did not receive two doses of the varicella vaccine earlier in life should be immunized. Essential hypertension is not a contraindication for this vaccine, making it safe to administer to this client. Choice A is incorrect because administering the Varicella vaccine is contraindicated during pregnancy due to the risk of transmission to the fetus. Choice B is incorrect because a severe allergy to neomycin is a contraindication to the Varicella vaccine, which contains a trace amount of neomycin. Choice C is incorrect because the Varicella vaccine is not recommended for infants under 12 months of age.
5. What dietary recommendations are given to a patient with pre-dialysis end-stage kidney disease?
- A. Reduce phosphorus intake to 700 mg/day
- B. Increase sodium intake
- C. Restrict protein intake to 0.55-0.60 g/kg/day
- D. Increase protein intake
Correct answer: A
Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. Excessive phosphorus intake can be harmful to individuals with kidney disease as their kidneys may not be able to excrete it efficiently. Choice B is incorrect because increasing sodium intake is generally not recommended for patients with kidney disease, as it can contribute to fluid retention and high blood pressure. Choice C is incorrect as protein restriction is commonly advised for individuals with advanced kidney disease to reduce the workload on the kidneys. Choice D is also incorrect as increasing protein intake can further burden the kidneys.
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