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Newest Actual Exam Review Q&A
with Definitive Answers / A+ Score
_____________Quiz____________? After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10. (c) A 55-year-old woman with ovarian cancer waiting to be discharged. (d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of 96% on room air. -
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Correct answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate attention. _____________Quiz____________? A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol) is being transferred in stable condition from the
intensive care unit to the medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this client is which of the following? (a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA). (b) A 28-year-old woman diagnosed with diarrhea. (c) A 72-year-old man with fever of unknown origin. (d) A 68-year-old woman with atrial fibrillation. -
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Correct answer: (d) A 68-year-old woman with atrial fibrillation. Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. Atrial fibrillation is not an infectious process. All other patients may be an infection risk for an individual with altered skin integrity. _____________Quiz____________? A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation centre. The nurse case manager is assisting in the process. The nurse knows that the goals of case management include which of the following? Select all that apply. (a) Improving the coordination of care (b) Increasing referrals to local organizations (c) Reducing the fragmentation of care (d) Discharging clients quickly -
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Correct answer: (a) Improving the coordination of care; and (c) Reducing the fragmentation of care Rationale: Some of the primary goals of case management are to improve the coordination of care and to reduce fragmentation of care. The other options are not goals of case management.
Correct answer: (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. Rationale: An individual not involved in the care of the client does not have a legitimate need to access the medical record. The nurse should protect the client's right to privacy by ensuring only authorized individuals access medical records. _____________Quiz____________? The nurse is learning how to use the hospital's new electronic medication administration record (eMAR). The nurse knows this tool has the potential to do which of the following? Select all that apply. (a) Reduce medication administration errors. (b) Improve access to information at the point of care. (c) Eliminate the need for the nurse to document medication administration. (d) Eliminate the need for the nurse to verify dose calculations. -
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Correct answer: (a) Reduce medication administration errors; and (b) Improve access to information at the point of care. Rationale: eMARs have the potential to reduce medication administration errors and to improve access to client information at the point of care. It is always the nurse's responsibility to document medication administration and to verify doses of drugs being administered. _____________Quiz____________? The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home. The nurse knows this type of information technology is best described as which of the following? (a) Encryption (b) Telecommunications
(c) Telehealth (d) Nursing informatics -
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Correct answer: (c) Telehealth. Rationale: Telehealth uses transmissions via telecommunications technology to transmit health information remotely. Encryption refers to the conversion of information to code during transmission to keep the information secure. Telecommunications refers to the electronic transmission of data over phone-based lines. Nursing informatics refers to a specialty of nursing that integrates nursing and computer science _____________Quiz____________? The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements best illustrates quality care delivery by the nurse? Select all that apply. (a) "Just focus on how lucky you are to have two healthy babies." (b) "We can arrange for follow-up visits with a home health nurse." (c) "Here is some information on support groups for parents of multiples." (d) "You will find it easier to formula-feed your babies at home." -
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Correct answer: (b) "We can arrange for follow-up visits with a home health nurse."; and (c) "Here is some information on support groups for parents of multiples." Rationale: A referral to home health care provides the client with opportunities for support and assistance during this transition; and a referral to support groups provides the client with opportunities for support and assistance during this transition. The other options are not appropriate for a new mother expressing concerns about her ability to cope. _____________Quiz____________? The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place the tasks the nurse would perform in the appropriate order. All options must be used.
has knowledge of asepsis and dressing changes; administers medications. Patient (a) is stable with an expected outcome. Patients (b) and (c) require assessment and nursing judgement; and Patient (d) involves a standard unchanging procedure that can be assigned to the nursing assistant. _____________Quiz____________? A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? (a) A client requiring colostomy irrigation (b) A client receiving continuous tube feedings (c) A client who requires stool specimen collections (d) A client who has difficulty swallowing food and fluids -
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Correct answer: (c) A client who requires stool specimen collections Rationale: This question addresses content related to delegation in the subcategory Management of Care in the Client Needs category of Safe and Effective Care Environment. Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. In this situation, the most appropriate assignment for the nursing assistant is to care for the client who requires stool specimen collections. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Remember, the health care provider needs to be competent and skilled to perform the assigned task or activity.
