Nokea
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
- A. Distended, hard, and rigid abdomen
- B. Clay-colored stool
- C. Radiating sharp pain in the right shoulder
- D. Bile-stained emesis
Correct Answer: A
Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.
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The client is being educated by the healthcare provider about risk factors associated with atherosclerosis and methods to reduce the risk. Which of the following is a risk factor that the client cannot modify?
- A. Diabetes
- B. Age
- C. Exercise level
- D. Dietary preferences
Correct Answer: B
Rationale: Age is a nonmodifiable risk factor for atherosclerosis because it is a natural part of the aging process. While lifestyle factors such as diabetes, exercise level, and dietary preferences can be modified to reduce the risk of atherosclerosis, age cannot be altered. Therefore, age is the correct answer. Diabetes, exercise level, and dietary preferences can all be improved or managed through interventions and lifestyle changes to mitigate the risk of atherosclerosis.
In a patient with chronic obstructive pulmonary disease (COPD), which of the following interventions is most important?
- A. Encouraging the patient to stop smoking.
- B. Administering bronchodilators.
- C. Monitoring oxygen saturation.
- D. Providing nutritional support.
Correct Answer: C
Rationale: Monitoring oxygen saturation is the most important intervention in a patient with COPD because it helps assess the adequacy of oxygenation. In COPD, patients often have compromised lung function, leading to decreased oxygen levels in the blood. Monitoring oxygen saturation allows healthcare providers to promptly identify and address any potential hypoxemia, which is vital in managing COPD exacerbations. While encouraging the patient to stop smoking (Choice A) is critical for long-term management, monitoring oxygen saturation takes precedence in the immediate care of a COPD patient. Administering bronchodilators (Choice B) and providing nutritional support (Choice D) are important aspects of managing COPD but are secondary to monitoring oxygen saturation, which directly impacts the patient's oxygenation status.
The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?
- A. Administer anticoagulants to prevent clot formation.
- B. Monitor the client for signs of infection.
- C. Provide the client with a high-protein diet.
- D. Encourage the client to drink at least 2 liters of fluid daily.
Correct Answer: B
Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.
A patient with a diagnosis of Cushing's syndrome is likely to exhibit which of the following symptoms?
- A. Hyperpigmentation.
- B. Moon face.
- C. Hypotension.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Moon face. Cushing's syndrome is characterized by excess cortisol levels, leading to the distinctive round and full face known as moon face. Hyperpigmentation (choice A) may occur due to increased ACTH levels, but it is not a hallmark symptom like moon face. Hypotension (choice C) is less common in Cushing's syndrome as cortisol typically leads to hypertension (choice D) due to its effects on blood pressure regulation.
During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?
- A. Initiate isolation precautions
- B. Administer an antipyretic
- C. Draw blood cultures
- D. Prepare for lumbar puncture
Correct Answer: A
Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.