Nokea
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
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A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
- A. Chest pain radiating to the left arm.
- B. Bilateral leg swelling.
- C. Fever.
- D. Dry cough.
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
- A. Physical therapy.
- B. Antibiotic therapy.
- C. Psychological therapy.
- D. Anti-inflammatory therapy.
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
- A. Hyponatremia
- B. Hypernatremia
- C. Hypochloremia
- D. Hyperchloremia
Correct Answer: A
Rationale: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
The nurse instructs a female client about collecting a midstream urine sample for culture and sensitivity. Which should the nurse include in client teaching?
- A. Bathe before collecting the specimen.
- B. Cleanse the perineum from front to back.
- C. Label specimen with the provider's name.
- D. Collect urine at the beginning of urination.
Correct Answer: B
Rationale: To prepare properly for collection of a sterile urine specimen, the client cleanses the perineum from front to back using antiseptic swabs. Bathing before a midstream urine collection is unnecessary; however, proper specimen handling is critically important because improper specimen handling can yield inaccurate test results. The specimen should be labeled with the client's name, date, time, and medical record number in addition to the provider's name. The client should begin the flow of urine and collect the sample after starting the flow of urine, and then send the specimen to the laboratory as soon as possible.