Nokea
A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.
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A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.
A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:
- A. Venereal Disease Research Lab (VDRL)
- B. Rapid plasma reagin (RPR)
- C. Florescent treponemal antibody (FTA)
- D. Thayer-Martin culture (TMC)
Correct Answer: C
Rationale: The fluorescent treponemal antibody (FTA) test is highly specific for Treponema pallidum, the causative agent of syphilis, and is the best diagnostic test.
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
- A. Wound infection
- B. Impaired circulation to the stump
- C. Incorrect wrap technique
- D. Bleeding into the tissues
Correct Answer: C
Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (C), which can cause uneven pressure. Infection (A), impaired circulation (B), or bleeding (D) would present differently.
Clients taking anticholinergic drugs, such as benztropine mesylate (Cogentin), to relieve muscle tremors and muscle rigidity associated with Parkinson disease should be advised to avoid which of the following?
- A. Overheating
- B. Overeating
- C. Excessive fluid intake
- D. Skipping meals
Correct Answer: A
Rationale: Anticholinergics like benztropine reduce sweating, increasing the risk of overheating (A). Overeating (B), excessive fluids (C), or skipping meals (D) are not directly related to anticholinergic side effects.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.