Nokea
A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is:
- A. Arteriosclerosis
- B. Aneurysm formation
- C. Deep vein thrombosis (DVT)
- D. Varicose veins
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a common cause of pulmonary embolism, as clots from the veins (often legs) can dislodge and travel to the lungs, causing acute shortness of breath. Arteriosclerosis, aneurysms, and varicose veins are less directly associated.
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A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
Blood pressure in the systemic circulation is highest in the:
- A. Arterioles
- B. Capillaries
- C. Aorta
- D. Venules
Correct Answer: C
Rationale: Blood pressure is highest in the aorta, where blood is ejected directly from the left ventricle during systole, generating peak pressure (systolic pressure). As blood flows through arterioles, capillaries, and venules, pressure progressively decreases due to resistance and vessel compliance. This makes the aorta the correct answer.
The expected outcome of using miotics to treat glaucoma is:
- A. Paralyzing ciliary muscles.
- B. Constricting intraocular vessels.
- C. Constricting the pupil.
- D. Relaxing ciliary muscles.
Correct Answer: C
Rationale: Miotics (e.g., pilocarpine) constrict the pupil, which opens the drainage angle of the eye, facilitating aqueous humor outflow and reducing intraocular pressure.
A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
- A. Awake the client
- B. Check the armband for client identification number and compare with the order
- C. Label the sample vial in front of the client
- D. Verify the room number with the room assignment
- E. Ask the client to state his/her name
Correct Answer: B,C,E
Rationale: Rationales: B) Checking the armband ensures correct client identification, critical for safety. C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity. A) Awakening the client is unnecessary if asleep, as the draw can be done gently. D) Room number is unreliable for identification.