Nokea
A 38-year-old client with a history of type 1 diabetes mellitus is admitted with an infected foot ulcer. The nurse should recognize that wound healing may be delayed because of:
- A. Increased tissue perfusion.
- B. Impaired collagen synthesis.
- C. Enhanced immune response.
- D. Increased fibroblast activity.
Correct Answer: B
Rationale: In diabetes, impaired collagen synthesis due to poor glycemic control delays wound healing, increasing infection risk.
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Your client has presented in the emergency department with a sudden onset of shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, neck, and back. Which of the following would you most likely suspect?
- A. Hypovolemic shock
- B. Septic shock
- C. A dissected thoracic aortic aneurysm
Correct Answer: C
Rationale: Sudden onset of these symptoms, especially chest and back pain, suggests a dissected thoracic aortic aneurysm, a life-threatening condition requiring urgent intervention.
A client with a history of cirrhosis is admitted with ascites. Which dietary modification should the nurse recommend?
- A. Low-sodium diet
- B. High-protein diet
- C. Low-fat diet
- D. High-carbohydrate diet
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention in ascites, helping to manage symptoms in clients with cirrhosis.
Which of the following security concerns is also a sentinel event that must be reported?
- A. A possible vulnerability of the facility's information technology to hacking
- B. The assisted suicide of a client in your facility by the spouse of the client
- C. Vulnerability to computer hacking
- D. Potential information theft
Correct Answer: B
Rationale: The assisted suicide of a client is a sentinel event, as it is an unexpected occurrence involving death, requiring immediate investigation and reporting per The Joint Commission standards.
A client with a history of chronic lymphocytic leukemia is prescribed rituximab (Rituxan). The nurse should monitor the client for which of the following side effects during infusion?
- A. Hypotension.
- B. Hyperglycemia.
- C. Infusion reactions.
- D. Weight loss.
Correct Answer: C
Rationale: Rituximab can cause infusion reactions, such as fever or chills, requiring close monitoring during administration.
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
- A. Infection
- B. Pneumothorax
- C. Aspiration
- D. Dyspnea
Correct Answer: B
Rationale: Pneumothorax is a potential complication of thoracentesis due to the risk of lung puncture during the procedure, requiring immediate monitoring.