Nokea
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
- A. Blood loss
- B. Intestinal hookworm
- C. Intestinal malabsorption
- D. Decreased intake of dietary iron
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.
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Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
- A. Estrogen.
- B. Estrogen and progestin.
- C. Progestin.
- D. Testosterone.
Correct Answer: C
Rationale: Progestin-only contraceptives are safe during breast-feeding, as they do not affect milk production.
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
- A. Tinnitus
- B. Ecchymoses
- C. Increased pulse rate
- D. Decreased blood pressure
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
- A. 15 to 30 minutes
- B. 1 to 2 hours
- C. 2 to 4 hours
- D. 4 to 6 hours
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.
The nurse is caring for a client with a history of breast cancer who is receiving radiation therapy. Which of the following instructions should the nurse include in the client's teaching?
- A. Apply lotion to the radiated area immediately after treatment.
- B. Avoid exposing the radiated area to sunlight.
- C. Wash the radiated area with soap and water daily.
- D. Wear tight clothing over the radiated area.
Correct Answer: B
Rationale: Avoiding sunlight exposure protects the radiated skin from further damage and reduces irritation.
A client is scheduled for a colonoscopy. Which of the following instructions should the nurse include in the pre-procedure teaching?
- A. Avoid solid foods for 24 hours before the procedure.
- B. Take all regular medications the morning of the procedure.
- C. Expect to be sedated during the procedure.
- D. Plan to stay overnight in the hospital.
Correct Answer: A, C
Rationale: Clear liquid diet for 24 hours prevents residue, and sedation is common during colonoscopy. Regular medications may need adjustment, and overnight stays are not typical.