Nokea
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
- A. I have been having trouble reading the newspaper.'
- B. I have pain up and down my legs.'
- C. My knees hurt when I climb stairs.'
- D. I am so tired of having a headache.'
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
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The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
- A. Encourage the client to drink 2 L of fluid daily.
- B. Administer antipyretics as ordered.
- C. Administer antibiotics as ordered.
- D. Administer mucolytics as ordered.
- E. Ambulate three times a day.
- F. Eat three large meals a day.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
A young adult client is scheduled for her first debridement of a second-degree burn of the left arm.
It is MOST important for the nurse to take which of the following actions?
- A. Assemble all necessary supplies and medications.
- B. Plan adequate time for the dressing change and provide emotional support.
- C. Prepare the client and family for the pain the client will experience during and after the procedure.
- D. Limit visitation prior to the procedure to reduce stress.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate, but is not a high priority (2) correct-planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure, but on providing the emotional support necessary for the client (3) appropriate, but is not a high priority (4) appropriate, but is not a high priority
A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
The nurse is caring for a client with a history of schizophrenia.
- A. Which client behavior indicates a positive response to antipsychotic medication?
- B. Increased social withdrawal.
- C. Improved ability to focus on tasks.
- D. Frequent auditory hallucinations.
- E. Increased agitation and pacing.
Correct Answer: B
Rationale: Improved ability to focus on tasks indicates reduced psychotic symptoms and better cognitive function, a positive response to antipsychotics. Withdrawal, hallucinations, and agitation suggest poor response.