Nokea
A client with a suspected small bowel obstruction reports severe pain and vomiting. Which diagnostic test should the nurse prepare the client for first?
- A. Abdominal X-ray.
- B. Barium enema.
- C. Colonoscopy.
- D. CT scan.
Correct Answer: A
Rationale: An abdominal X-ray is typically the first diagnostic test for a suspected small bowel obstruction to identify air-fluid levels or free air. Barium enema and colonoscopy are contraindicated in acute obstruction, and a CT scan may follow for detailed imaging. CN: Reduction of risk potential; CL: Synthesize
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A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat
- A. multiple sclerosis.
- B. human immunodeficiency virus (HIV).
- C. Parkinson's disease.
- D. Guillain-Barré syndrome.
Correct Answer: B
Rationale: Tenofovir and emtricitabine (Truvada) are antiretroviral medications used to treat and prevent HIV. They are not used for multiple sclerosis (A), Parkinson’s disease (C), or Guillain-Barré syndrome (D).
The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning?
- A. Pulmonary edema
- B. Tinnitus
- C. Nausea and vomiting
- D. Tachycardia
Correct Answer: A
Rationale: Pulmonary edema is life-threatening and indicates severe aspirin toxicity, potentially leading to respiratory failure.
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
- A. Respiratory rate greater than 16 breaths/minute.
- B. Continuous bubbling in the water-seal chamber.
- C. Fluid in the chest tube.
- D. Fluctuation of fluid in the water-seal chamber.
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring physician notification. A respiratory rate >16 is normal. Fluid in the tube and fluctuation are expected.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.