Nokea
A client with a history of ovarian cancer is admitted with complaints of abdominal swelling. The nurse should give priority to:
- A. Monitoring for ascites
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal swelling in ovarian cancer often indicates ascites, so monitoring for ascites is the priority to guide treatment.
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A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 9:00 AM
- B. 1:00 PM
- C. 11:00 AM
- D. 3:00 PM
Correct Answer: C
Rationale: This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. This time is incorrect because it is after lunch when the NPH peaks. Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. This time is incorrect because it is before the NPH and after the regular insulin peak times.
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Lidocaine (Xylocaine)
- C. Quinidine gluconate or sulfate (Quinaglute, Quinidex)
- D. Nitroglycerin IV (Tridil)
Correct Answer: B
Rationale: Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
- A. Mild abdominal cramping
- B. Bright red blood in the stool
- C. Slight drowsiness
- D. Flatulence
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (A), drowsiness (C), and flatulence (D) are expected.
Which of the following diagnoses require droplet precautions?
- A. Varicella
- B. Rubella
- C. Streptococcal pharyngitis
- D. Scarlet fever
- E. Shigella
- F. Hepatitis A
Correct Answer: B, C, D
Rationale: Rubella (B), streptococcal pharyngitis (C), and scarlet fever (D) are transmitted via respiratory droplets, requiring droplet precautions. Varicella (A) requires airborne precautions, while Shigella (E) and hepatitis A (F) are transmitted fecally-orally, requiring contact precautions.
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. Five minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Correct Answer: D
Rationale: Chemical sunscreens require 30 minutes to absorb into the skin for optimal UV protection. Applying closer to exposure reduces effectiveness.