Nokea
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
- A. True urinary output of 50ml/hr
- B. Lower abdominal tenderness
- C. Blood urine output with clots
- D. Urine leaking around the meatus
Correct Answer: D
Rationale: Urine leaking around the meatus may indicate catheter displacement or obstruction, requiring immediate attention to prevent complications.
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A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
- A. Excruciating pain on inspiration
- B. Left lateral chest wall pain
- C. Disorientation and confusion
- D. Numbness and tingling of the arm
Correct Answer: C
Rationale: Older adults may present with atypical symptoms of myocardial infarction, such as confusion or disorientation, rather than classic chest pain.
The causative organisms for endocarditis in pediatric patients are
- A. enterococci
- B. group B streptococci
- C. viridans-type streptococci
- D. Pseudomonas aeruginosa
Correct Answer: C
Rationale: Viridans streptococci are the most common cause of endocarditis in pediatric patients.
A client with chronic kidney disease (CKD) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4°F (38°C), heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?
- A. Potassium 6.5 mEq/L (mmol/L)
- B. Potassium 6 mEq/L (mmol/L)
- C. Potassium 0.5 mEq/L (mmol/L)
- D. Potassium 1.5 mEq/L (mmol/L)
Correct Answer: A
Rationale: Elevated potassium levels in CKD clients can lead to life-threatening arrhythmias, so this result needs immediate intervention.
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best evidence that the client is adhering to the prescribed diabetic regimen?
- A. Hemoglobin A1C of 6.2%
- B. Fasting blood glucose of 130 mg/dL
- C. Positive urine ketones
- D. Self-reported daily blood glucose monitoring
Correct Answer: A
Rationale: A hemoglobin A1C of 6.2% indicates good glycemic control, reflecting adherence to the diabetic regimen.
Which patient could require feeding by gavage?
- A. Infant with congestive heart failure (CHF)
- B. Toddler with repair of transposition of the great vessels
- C. Toddler with Kawasaki disease (KD) in the acute phase
- D. School-age child with rheumatic fever (RF) and chorea
Correct Answer: B
Rationale: Feeding by gavage may be required if the child is unable to feed orally without increased cardiac demand, as might be seen after surgical repair of transposition of the great vessels.