Nokea
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Excessive sweating above the injury level.
- D. Numbness in the lower extremities.
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
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A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
- A. Maintain circulation
- B. Prevent infection
- C. Relieve pain
- D. Provide education
Correct Answer: A
Rationale: The primary goal post-bypass surgery for PVD is to maintain circulation, ensuring graft patency and adequate blood flow to the extremity to prevent ischemia or graft failure. Infection prevention, pain relief, and education are important but secondary to circulation.
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as:
- A. Negative.
- B. Needing to be repeated.
- C. Positive.
- D. False.
Correct Answer: C
Rationale: A positive tuberculin skin test (induration ‰¥10 mm in most cases) indicates exposure to Mycobacterium tuberculosis. Without the figure, the context suggests a positive result based on typical test interpretation.
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.