Nokea
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
- A. Bronchial breath sounds at lung periphery
- B. Clear vesicular breath sounds at lung bases
- C. Diffuse bilateral crackles at lung bases
- D. Stridor in upper airways
Correct Answer: C
Rationale: Frothy, pink-tinged sputum and dyspnea indicate pulmonary edema, a complication of myocardial infarction. Diffuse bilateral crackles are heard due to fluid in the alveoli.
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A client has just been diagnosed with diabetes and is admitted for insulin regulation. The client asks the nurse, 'Why do I need to be stuck so many times per day?' Which of the following statements best explains the rationale for checking the client's blood glucose level frequently?
- A. Blood glucose levels need to be checked every hour to ensure constant insulin needs.'
- B. Any fluctuation in blood glucose levels must be avoided.'
- C. Blood glucose levels are checked to be able to adjust the dosage of your insulin.'
- D. Elevations in glucose can result in alkalosis.'
Correct Answer: C
Rationale: Frequent blood glucose checks allow for insulin dose adjustments to maintain glycemic control. Hourly checks are excessive, fluctuations are managed not avoided, and alkalosis is unrelated to glucose elevations.
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: Loss of consciousness. This indicates anoxia, which may lead to death, requiring immediate reporting.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.
The nurse assesses a child with intussusception. Which assessment findings require priority intervention?
- A. Abdominal rigidity with guarding
- B. Absence of tears in crying child with IV start
- C. Blood-streaked mucous stool in diaper
- D. Sausage-shaped right-sided mass on palpation
Correct Answer: A
Rationale: Abdominal rigidity with guarding suggests peritonitis or perforation, critical complications of intussusception requiring immediate surgical intervention.
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.