Extract:

Question 1 of 5

What is the purpose of administering diphenhydramine before a blood transfusion?

Correct Answer: A

Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.

Question 2 of 5

The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?

A. Bed rest for 48 hours B. Light ambulation as tolerated C. Heavy lifting after 24 hours D. High-intensity exercise

Correct Answer: B

Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.

Question 3 of 5

Select the nurse case management model used for patient care delivery that is accurately paired with one of its descriptors:

A. The ProACT Model: Registered nurses perform the role of the primary nurse in addition to the related coding and billing functions B. The Collaborative Practice Model: The registered nurse performs the role of the primary nurse in addition to the role of the clinical case manager with administrative, supervisory and fiscal responsibilities C. The Case Manager Model: The management and coordination of care for clients throughout a facility who share the same DRG or medical diagnosis D. The Triad Model of Case Management: The joint collaboration of the social worker, the nursing case manager, and the utilization review team

Correct Answer: D

Rationale: The Triad Model of Case Management accurately describes the collaboration among the social worker, nursing case manager, and utilization review team to coordinate care and optimize outcomes.

Question 4 of 5

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.

A. Having suction equipment readily available B. Keeping all the lights on in the room at night C. Keeping a padded tongue blade at the bedside D. Assisting the client to ambulate in the hallway E. Monitoring the client closely while showering F. Locking the client's bed in its lowest position

Correct Answer: A,D,E,F

Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.

Question 5 of 5

Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.

A. Remove any dentures. B. Remove contact lenses. C. Provide access to limited food and drink. D. Ensure that the informed consent is signed. E. Have the client void before transport to endoscopy.

Correct Answer: A,B,D,E

Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.