Nokea
A client presents to the emergency room with severe pain in the upper right abdomen. The client is nauseated and has a temperature of 102.2°F. Which nursing action would be a priority at this time?
- A. relieve pain
- B. obtain vital signs
- C. administer IV fluids
- D. prepare for surgery
Correct Answer: B
Rationale: Obtaining vital signs (B) is the priority to assess stability in a client with suspected cholecystitis or appendicitis. Pain relief (A), fluids (C), and surgery (D) follow assessment.
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The nurse is preparing to remove a client's abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?
- A. clean the stitches with soap and water before removing
- B. wash the hands and use gloves while removing the stitches
- C. wash the hands and use sterile technique when removing the stitches
- D. wear a gown, gloves, a mask, an eye shield, and shoe covers during the procedure
Correct Answer: B
Rationale: Hand washing and gloves (B) are sufficient for stitch removal, a clean procedure. Soap/water (A) is unnecessary, sterile technique (C) is excessive, and full PPE (D) is not required.
The nurse is caring for a client with suspected connective tissue disease. Assessment findings include chronic back pain, weight loss, joint pain and itching, and visual disturbances. The nurse anticipates a diagnosis of which disorder for this client?
- A. Reiter syndrome
- B. Marfan syndrome
- C. ankylosing spondylitis
- D. systemic necrotizing vasculitis
Correct Answer: D
Rationale: Systemic necrotizing vasculitis (D) causes back/joint pain, weight loss, itching, and visual issues due to vessel inflammation. Reiter (A) involves arthritis/urethritis, Marfan (B) affects connective tissue, and ankylosing spondylitis (C) primarily causes spinal stiffness.
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
- A. hypertension; slow, labored breathing
- B. decreased urine output; warm, pink skin
- C. increased urine output; cool, clammy skin
- D. hypotension; weak pulse; cool, clammy skin
Correct Answer: D
Rationale: Cardiogenic shock causes hypotension, weak pulse, and cool, clammy skin (D) due to poor perfusion. Hypertension (A), warm skin (B), and increased urine output (C) are inconsistent with shock.
The nurse is precepting a student nurse on leukemia classifications. Which statement by the student nurse reflects an understanding of classifications of leukemia?
- A. Acute lymphocytic leukemia has an average age of onset of 15 to 39 years.
- B. Chronic myelogenous leukemia contains mostly granulocytes in the bone marrow.
- C. Chronic myelogenous leukemia has mostly lymphocytes found in the bone marrow.
- D. Acute myelogenous leukemia has primarily granulocytes present in the bone marrow.
Correct Answer: B
Rationale: Chronic myelogenous leukemia (CML) involves mostly granulocytes (B) in the bone marrow. ALL onset is younger (A), CML does not involve lymphocytes (C), and AML includes various cells, not primarily granulocytes (D).
A student nurse is precepting on the cardiac unit with the charge nurse. The charge nurse is educating the student about heart sounds and asks the student nurse to describe what causes the S1 sound. Which response by the student nurse reflects an understanding of cardiac sounds?
- A. It is caused by the mitral and tricuspid valves closing.
- B. It is caused by the mitral and pulmonic valves closing.
- C. It is caused by the pulmonic and aortic valves closing.
- D. It is caused by the aortic and tricuspid valves closing.
Correct Answer: A
Rationale: S1 is caused by the closure of mitral and tricuspid valves (A) at the start of systole. Pulmonic and aortic valves (C) cause S2, and other combinations (B, D) are incorrect.