the nurse is receiving a report from an er nurse about a client which of the following statements requires additional follow up

NCLEX-PN

Best NCLEX Next Gen Prep

1. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
B. "The client frequently takes antacids, but they have not taken any in the last three days."?
C. "The client stopped taking ibuprofen after developing gastric ulcers."?
D. "The client takes Antabuse and has stopped using mouthwash."?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

2. An allergic reaction is classified as what type of pharmacological effect?

A. a therapeutic effect
B. a side effect
C. an adverse effect
D. an incompatibility

Correct answer: C

Rationale: An allergic reaction is classified as an adverse effect because it is an unintended response to a medication that requires treatment. A side effect is an undesired but somewhat expected reaction to a drug that does not necessarily need intervention. Incompatibility refers to an unsuitable combination of substances that leads to an adverse effect. A therapeutic effect is the desired and intended outcome of a medication.

3. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

A. refusal to walk
B. not pulling to a standing position
C. negative Trendelenburg sign
D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.

4. A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent?

A. Using a latex condom is a good method for reducing the risk of sexually transmitted infections (STIs).
B. The only way to reduce the risk of transmission of STIs is abstinence.
C. A spermicide needs to be used along with a condom to prevent transmission of STIs.
D. Using a latex condom can reduce the risk of transmission of STIs.

Correct answer: D

Rationale: The correct answer is that using a condom during intercourse can reduce the risk of STI transmission. Abstinence is a way to prevent STIs, but not the only way. Using a spermicide along with a condom can help prevent pregnancy, not STIs. While condoms may fail to prevent pregnancy, they are effective in reducing the risk of STI transmission. Therefore, using a latex condom for pregnancy prevention is not directly related to preventing the transmission of STIs.

5. What are major competencies for the nurse giving end-of-life care?

A. demonstrating respect and compassion, and applying knowledge and skills in the care of the family and the client.
B. assessing and intervening to support total management of the family and client.
C. setting goals, expectations, and dynamic changes to care for the client.
D. keeping all sad news away from the family and client.

Correct answer: A

Rationale: Major competencies for nurses providing end-of-life care involve a combination of skills and qualities. Demonstrating respect and compassion towards the family and the client is essential in end-of-life care. Additionally, applying knowledge and skills in caring for both the family and the client is crucial to ensure comprehensive and compassionate care. Option A is the correct choice as it accurately reflects these key competencies. Option B, which focuses on assessing and intervening for total management, is important but does not fully address the holistic approach necessary for end-of-life care. Option C, about setting goals and expectations, is relevant but not as critical as the core competencies mentioned in option A. Option D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.