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1. Which of the following is an example of a tertiary prevention activity?
- A. Administering immunizations
- B. Physical therapy for stroke patients
- C. Routine health screenings
- D. Health education campaigns
Correct answer: B
Rationale: The correct answer is B, physical therapy for stroke patients. Tertiary prevention aims to prevent complications and improve the quality of life for individuals who already have a disease or condition. Administering immunizations (choice A) is an example of primary prevention to prevent the onset of diseases. Routine health screenings (choice C) are part of secondary prevention to detect diseases early. Health education campaigns (choice D) typically fall under primary prevention by educating and promoting healthy behaviors to prevent diseases.
2. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct answer: A
Rationale: In a client experiencing vomiting and diarrhea, the nurse should expect findings such as dehydration, which can lead to hypovolemia and subsequent increased heart rate and decreased blood pressure. A blood pressure of 144/82 mm Hg is indicative of possible dehydration in this client. Urine specific gravity is typically increased in dehydrated individuals, so choices B and D are incorrect. Neck vein distention is not a typical finding associated with vomiting and diarrhea; therefore, choice C is also incorrect.
3. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
- A. Wear an N95 respirator when giving direct care to the client.
- B. Place the client in a private room with negative-pressure airflow.
- C. Ensure the client's room has at least six air exchanges per hour.
- D. Ensure the client wears a mask when outside their room if there is construction in the area.
Correct answer: A
Rationale: In a protective environment for a client with an allogeneic stem cell transplant, the nurse needs to wear an N95 respirator when providing direct care to the client. This precaution is essential to protect the client, whose immune system is compromised after the transplant, from exposure to potential pathogens. Placing the client in a private room with negative-pressure airflow (choice B) is more appropriate for clients with airborne infections. Ensuring the client's room has sufficient air exchanges (choice C) is important for maintaining air quality but is not the primary precaution for protecting an immunocompromised client. Making the client wear a mask when outside the room due to construction (choice D) focuses on external factors and does not directly address the risk of infection during direct care.
4. Which of the following factors may affect successful communication?
- A. Cultural background
- B. Organizational structure
- C. Method of communication
- D. All of the above
Correct answer: D
Rationale: Various factors can influence successful communication. Cultural background is crucial as different cultures may have distinct communication styles and norms. Organizational structure plays a role by determining the flow of information within an organization. The method of communication chosen can impact the clarity and effectiveness of the message being conveyed. Therefore, all the options provided - cultural background, organizational structure, and method of communication - can affect successful communication, making 'All of the above' the correct answer.
5. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
- A. Compare the client's home medications with the provider's prescriptions
- B. Place the client's home medication bottles in a secure location
- C. Call the pharmacy to determine whether the client's medications are available
- D. Verify the client's name on their identification bracelet with the medication administration record
Correct answer: A
Rationale: The correct answer is A. During medication reconciliation, the nurse should compare the client's home medications with the provider's prescriptions to ensure accurate and safe administration. This process helps identify any discrepancies or potential interactions. Choice B is incorrect because placing the client's home medication bottles in a secure location is not part of medication reconciliation. Choice C is incorrect as calling the pharmacy to determine medication availability is not related to reconciling medications. Choice D is incorrect as verifying the client's name on their identification bracelet with the medication administration record is part of the identification process, not medication reconciliation.
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