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Question 1 of 5

The nurse is talking with a client with atrial fibrillation who has a new prescription for dabigatran. Which of the following statements by the client would require follow-up?

Correct Answer: D

Rationale: Dabigatran does not require routine blood monitoring (
D), unlike warfarin, so this statement requires follow-up. Soft toothbrush (
A), reporting bleeding (
B), and swallowing whole (
C) are correct.

Question 2 of 5

A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

Correct Answer: A, B, C

Rationale: Documenting in the EHR (
A), discussing with the proxy (
B), and completing an advance directive (
C) ensure the client's wishes are communicated. Informed consent (
D) is irrelevant, and DNR (E) is not indicated.

Question 3 of 5

The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.

Correct Answer: A, B, C, E

Rationale: Clear liquids include apple juice (
A), chicken broth (
B), cranberry juice (
C), and unsweetened tea (E). Cream of chicken soup (
D) and ice cream (F) are not clear liquids.

Question 4 of 5

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.

Correct Answer: B, C

Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (
B) and postpartum client (
C). It's contraindicated for infants under 2 (
A), pregnant women (
D), and immunocompromised clients (E).

Question 5 of 5

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?

Correct Answer: B

Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (
B) is the priority to minimize harm and promote safety. Bipolar history (
A), ECG changes (
C), and blood alcohol level (
D) are important but less urgent.

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