Nokea
A 57-year-old male with a history of vasculitis has purple discolorations on his legs, each approximately 0.3 cm to 1 cm in size. He asks the nurse what these discolorations are called, and the nurse correctly calls them
- A. ecchymosis.
- B. purpura.
- C. petechia.
- D. bruises.
Correct Answer: B
Rationale: Purpura are purple discolorations 0.3-1 cm, often seen in vasculitis due to small vessel bleeding. Petechiae are smaller (<0.3 cm), and ecchymosis is larger (>1 cm).
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The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
Which client is at greatest risk for a caesarean section due to cephalopelvic disproportion (CPD)?
- A. A 25-year-old gravida 2, para 1
- B. A 30-year-old gravida 3, para 2
- C. A 17-year-old gravida 1, para 0
- D. A 32-year-old gravida 1, para 0
Correct Answer: C
Rationale: A 17-year-old primigravida is at higher risk for CPD due to a potentially underdeveloped pelvis, increasing the likelihood of cesarean delivery.
The client taking Glyburide (Diabeta) should be cautioned to:
- A. Avoid eating sweets
- B. Report changes in urinary pattern
- C. Allow 3 hours for onset
- D. Check the glucose daily
Correct Answer: D
Rationale: Daily glucose monitoring is essential for clients on Glyburide to manage blood sugar levels effectively.
The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?
- A. Arterial blood gas POâ‚‚ of 98
- B. Increase in lethargy
- C. Pupils slow to react to light
- D. Temperature of 101°F
Correct Answer: A
Rationale: An arterial blood gas POâ‚‚ of 98 indicates adequate oxygenation, supporting cerebral perfusion, which is a favorable outcome for a subdural hematoma.