Nokea
A 66-year-old woman is being evaluated for pernicious anemia. Which assessment findings would be most apt to be present in a client with pernicious anemia?
- A. Easy bruising
- B. Pain in the legs
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes neurological symptoms like leg pain or paresthesia. Bruising, rashes, or pruritus are less specific to this condition.
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A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
The nurse is making a home visit for a client with an abdominal wound.
When irrigating the draining wound with a sterile saline solution, which of the following sequences would be MOST appropriate for the nurse to follow?
- A. Pour the solution, wash hands, and remove the soiled dressing.
- B. Wash hands, prepare the sterile field, and remove the soiled dressing.
- C. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
- D. Remove the soiled dressing, flush the wound, and wash hands.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hands should be washed first (2) correct-handwashing should be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first
A terminally ill client says to the nurse, 'Do you believe in heaven?' How should the nurse respond?
- A. Yes, I believe in heaven and hell.'
- B. My personal belief is private.'
- C. Do you believe in heaven?'
- D. Do you want to see your clergyman?'
Correct Answer: C
Rationale: Reflecting the question back encourages the client to share beliefs, fostering spiritual discussion. Sharing personal beliefs, withholding, or redirecting are less therapeutic.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.