Nokea
Which of the following is a common complication of immobility?
- A. Muscle hypertrophy.
- B. Pressure ulcers.
- C. Bone fractures.
- D. Joint stiffness.
Correct Answer: B
Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.
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What is the most common cause of urinary tract infections (UTIs)?
- A. Escherichia coli infection
- B. Staphylococcus aureus infection
- C. Pseudomonas aeruginosa infection
- D. Klebsiella pneumoniae infection
Correct Answer: A
Rationale: Escherichia coli is the most common cause of urinary tract infections (UTIs). It is responsible for the majority of UTIs, especially in women. E. coli is a normal inhabitant of the bowel and can enter the urinary tract through the urethra, leading to infection. Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae are less common causes of UTIs compared to E. coli. Staphylococcus aureus typically causes skin and soft tissue infections, Pseudomonas aeruginosa is more commonly associated with healthcare-associated infections, and Klebsiella pneumoniae is known for causing pneumonia and other respiratory infections.
The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1000 ml of gastric secretions were collected in the last 4 hours. What condition is the client at risk for developing?
- A. Metabolic alkalosis
- B. Hyperkalemia
- C. Metabolic acidosis
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Metabolic alkalosis. Loss of gastric secretions, which contain stomach acid, can lead to metabolic alkalosis. Excessive loss of acid results in an increase in the blood pH, leading to alkalosis. Hyperkalemia (B) is an elevated potassium level and is not directly related to the loss of gastric secretions. Metabolic acidosis (C) is an acid-base imbalance characterized by low pH and bicarbonate levels, which is the opposite of what would occur with the loss of gastric secretions. Hypoglycemia (D) is low blood sugar and is not typically associated with the scenario described in the question.
Which of the following is the most important nursing action when administering a blood transfusion?
- A. Monitoring the patient's blood pressure.
- B. Monitoring the patient's temperature.
- C. Monitoring the patient's heart rate.
- D. Monitoring the patient's oxygen saturation.
Correct Answer: A
Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.
The client with peripheral artery disease has been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following?
- A. I should not be surprised if I bruise more easily or if my gums bleed a little when brushing my teeth.
- B. It is important to take this medicine with food to enhance its effectiveness and minimize stomach upset.
- C. I should stop taking Plavix if it makes me feel weak and dizzy.
- D. The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming.
Correct Answer: C
Rationale: The correct answer is C. Weakness, dizziness, and headache are common adverse effects of Plavix and should be reported. It is essential to consult a physician before stopping Plavix as it plays a crucial role in preventing platelets from sticking together and forming clots. Choices A, B, and D are incorrect. Choice A is a common side effect of Plavix and does not indicate a need for further teaching. Choice B is incorrect because taking Plavix with or without food can affect its absorption and effectiveness. Choice D correctly explains the purpose of prescribing Plavix to prevent clot formation.