Nokea
The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.
- A. Dysuria
- B. Jaundice
- C. Low back pain
- D. Night sweats
- E. Weight loss
- F. Purulent or blood-tinged sputum
Correct Answer: D,E,F
Rationale: Night sweats, weight loss, and purulent/blood-tinged sputum are hallmark symptoms of pulmonary tuberculosis.
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A nurse is caring for a client following the delivery of a stillborn infant. Which of the following actions should the nurse take? Select all that apply.
- A. Ask the parents if they would like to help bathe the infant
- B. Discourage the parents from naming the infant
- C. Discuss the importance of organ donation with the parents
- D. Encourage the parents and family members to hold the infant
- E. Offer to obtain handprints, footprints, and photographs of the infant
Correct Answer: A,D,E
Rationale: Bathing, holding, and obtaining mementos support grieving. Naming is a personal choice, and organ donation discussions may be inappropriate at this time.
The nurse is caring for a 2-year-old client who has iron deficiency anemia. The nurse should recognize that this condition is most likely the result of
- A. impaired iron transfer from the mother
- B. excessive intake of meat products
- C. excessive intake of cow's milk
- D. gastrointestinal blood loss
Correct Answer: C
Rationale: Excessive cow's milk intake in toddlers can lead to iron deficiency anemia due to low iron content and potential for gastrointestinal irritation.
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
- A. The client's self-report is the most important consideration
- B. Cultural sensitivity is fundamental to pain management
- C. Clients have the right to pain management
- D. Nurses should not prejudge a client's pain using their own values
Correct Answer: A
Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.
A client is scheduled for a cataract extraction. Preoperatively, 1% atropine is instilled into the client's right eye. The nurse knows that this drug would be contraindicated if the client also had which of the following conditions?
- A. Bradycardia
- B. Hypothyroidism
- C. Diabetes
- D. Glaucoma
Correct Answer: D
Rationale: Atropine, an anticholinergic, increases intraocular pressure, worsening glaucoma. Bradycardia, hypothyroidism, or diabetes are not contraindications for ocular atropine.