Nokea
A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:
- A. Monitoring for recurrence
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.
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The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?
- A. Occasional small amounts of hemoptysis
- B. Midline trachea with wheezing on auscultation
- C. Subcutaneous air and absent breath sounds
- D. Pain when breathing deeply, with rales in the upper lobes
Correct Answer: C
Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (A), wheezing (B), and pain/rales (D) are concerning but less urgent.
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:
- A. I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.
- B. It is not too much trouble. This is the best way to manage urination.
- C. OK. I'll ask your physician if we can replace the Foley.
- D. You need to learn this because your doctor ordered it.
Correct Answer: A
Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.
The physician orders Zestril (lisinopril) and Lasix (furosemide) to be administered at the same time to a client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications as ordered
- C. Administer the medications separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril (an ACE inhibitor) and furosemide (a diuretic) are commonly prescribed together for hypertension to reduce blood pressure synergistically. Administering them as ordered is appropriate as there is no contraindication to concurrent use.
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Urine output 22 mL/hr for 2 hours
- B. Serum potassium level of 3.7
- C. Small T wave of ECG
- D. Serum glucose level of 180
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.