Nokea
A client is admitted with possible appendicitis. Which finding by the nurse would be expected in assessment of this client?
- A. a positive psoas sign
- B. a positive Murphy's sign
- C. a positive Homan's sign
- D. a positive Chadwick's sign
Correct Answer: A
Rationale: A positive psoas sign (pain with leg extension) is associated with appendicitis. Murphy’s sign is for gallbladder, Homan’s for DVT, and Chadwick’s for pregnancy.
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The nurse is caring for a female client following the removal of the parathyroid glands. The client complains of a 'pins and needles' sensation and difficulty swallowing lunch. The nurse would expect which laboratory value to be abnormal?
- A. calcium
- B. potassium
- C. magnesium
- D. blood glucose
Correct Answer: A
Rationale: Parathyroidectomy can cause hypocalcemia, leading to paresthesia ('pins and needles') and dysphagia due to muscle dysfunction.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.
A critically injured woman is rushed to the ER. She needs an immediate blood transfusion, and there is no time to crossmatch blood type. The nurse anticipates the physician will call for
- A. 1 unit of AB positive blood.
- B. 1 unit of O positive blood.
- C. 1 unit of AB negative blood.
- D. 1 unit of O negative blood.
Correct Answer: D
Rationale: O negative blood is the universal donor, safe for emergency transfusions without crossmatching, minimizing reaction risk.
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.
A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck. Which exam would assist the physician to make a tentative diagnosis of leukemia?
- A. A complete blood count
- B. An x-ray of the chest
- C. A bone marrow aspiration
- D. A CT scan of the abdomen
Correct Answer: A
Rationale: A complete blood count (CBC) is the initial test for leukemia, revealing abnormal white blood cell counts, anemia, or thrombocytopenia, supporting a tentative diagnosis.