Nokea
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
- A. For clients with an inevitable death within weeks to months
- B. For all clients with AIDS at any stage
- C. Only for clients with cancer
- D. When the client is ready to discuss his prognosis
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
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The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
- A. Fatigue
- B. Dyspnea
- C. Bradycardia
- D. Muscle cramps
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.