Nokea
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
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For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
- A. Hypoglycemia.
- B. Hypercalcemia.
- C. Hypermagnesemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
- A. Pallor
- B. Hypertension
- C. A low hematocrit level
- D. Pale mucous membranes
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
The nurse is caring for a client with a history of venous thromboembolism who is prescribed rivaroxaban (Xarelto). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with rivaroxaban, requiring immediate reporting.
The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
- A. Ribs
- B. Femur
- C. Scapula
- D. Sternum
Correct Answer: D
Rationale: The most common sites for bone marrow biopsy in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are not sites for bone marrow biopsy.
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
- A. Use the meter only when symptoms are present.
- B. Record the highest of three readings.
- C. Clean the meter with soap and water weekly.
- D. Blow into the meter as slowly as possible.
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.