Nokea
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
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Iron drops were ordered for a toddler who has iron deficiency anemia. What observation of the child by the nurse indicates that the child is receiving the medication?
- A. The child is pale and lethargic.
- B. The child's skin has brown spots.
- C. The child's urine is dark colored.
- D. The child's stools are black.
Correct Answer: D
Rationale: Iron supplements commonly cause black stools due to unabsorbed iron, indicating medication use. Pallor, brown spots, or dark urine are unrelated.
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
- A. Administering insulin once per day
- B. Administering multiple doses of insulin
- C. Limiting dietary fat intake
- D. Substituting an oral antidiabetic agent for insulin
Correct Answer: B
Rationale: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
Should Mr. Dubin develops hemolytic transfusion reaction, nurse will immediately stop the transfusion and then
- A. run the IV NS.
- B. send the remaining blood to the lab.
- C. monitor the vital signs.
- D. collect urine specimen to be sent to the lab.
Correct Answer: A
Rationale: Normal Saline is compatible with blood transfusion and should be run to maintain IV access after stopping the transfusion. The physician must be informed after running the NS.
When does the discharge training and planning begin for this patient?
- A. Following surgery.
- B. Upon admit.
- C. Within 48 hours.
- D. Preoperative discussion.
Correct Answer: B
Rationale: Discharge planning begins upon admission to ensure a comprehensive care plan.
A patient is prescribed levothyroxine (Synthroid) for hypothyroidism. Which of the following instructions should the nurse include in the teaching plan?
- A. Take this medication with food
- B. Take this medication at bedtime
- C. Take this medication on an empty stomach
- D. Take this medication with a glass of milk
Correct Answer: C
Rationale: Levothyroxine is best absorbed on an empty stomach, ensuring efficacy. Food or milk reduces absorption, and bedtime dosing is less critical than morning administration.