Nokea
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?
- A. Low-grade fever.
- B. Muscle atrophy.
- C. Hematuria.
- D. Joint pain.
Correct Answer: C
Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.
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A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Increase oxygen flow rate during physical activity
- B. Smoke at least 10 feet away from the oxygen source
- C. Use petroleum jelly to prevent nasal dryness
- D. Ensure the oxygen tank is stored in a secure upright position
Correct Answer: D
Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
Which other congenital defects are common in children with Down syndrome?
- A. Hypospadias
- B. Pyloric stenosis
- C. Heart defects
- D. Hip dysplasia
Correct Answer: C
Rationale: The correct answer is C: Heart defects. Many children with Down syndrome are born with congenital heart defects. These heart abnormalities are more prevalent in individuals with Down syndrome than in the general population. Choices A, B, and D are incorrect because while they may be congenital defects in children, they are not commonly associated with Down syndrome. Hypospadias is a urogenital condition, pyloric stenosis affects the stomach, and hip dysplasia involves the hip joint, but these are not typically seen as frequently as heart defects in children with Down syndrome.
In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?
- A. Atherosclerotic plaque formation.
- B. Stasis of blood flow.
- C. Endothelial damage.
- D. Atherosclerotic vessel changes.
Correct Answer: B
Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.
A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?
- A. Reinforce the incisional dressings and assess behind the neck for drainage.
- B. Place the client in a right lateral side-lying position and elevate the head of the bed.
- C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.
- D. Compress the bulb with the tab open and then reinsert the tab into its opening.
Correct Answer: D
Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.