Nokea
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter size blood spot on dressing
- D. Pitting ankle edema
Correct Answer: A
Rationale: An irregular apical pulse could indicate cardiac complications, which are a risk in clients with Cushing's syndrome due to fluid and electrolyte imbalances.
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An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Teach a family member to administer eye drops
- B. Encourage deep breathing and coughing exercises
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization
Correct Answer: C
Rationale: An eye shield protects the surgical site from accidental trauma during sleep, which is critical for postoperative healing.
What are FIVE indications for pacemaker insertion in a child with congenital heart block?
- A. Symptomatic bradycardia
- B. Ventricular dysfunction or low cardiac output
- C. Wide QRS escape
- D. Complex ventricular ectopy
Correct Answer: A
Rationale: Symptomatic bradycardia is the most common indication for pacemaker insertion in children with congenital heart block, to ensure adequate heart rate and perfusion.
A child with rheumatic fever is being admitted to the pediatric floor. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
- A. “Has your child complained of back pain?â€
- B. “Has your child complained of headaches?â€
- C. “Has your child had any nausea or vomiting?â€
- D. “Did your child have a sore throat or fever within the last 2 months?â€
Correct Answer: D
Rationale: A history of sore throat or fever within the last 2 months is significant as rheumatic fever often follows a streptococcal infection such as strep throat.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low.
- B. Would you like to speak with a chaplain before surgery?
- C. Tell me more about your concerns about the surgery.
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: Encouraging the client to express their concerns allows the nurse to provide emotional support and address specific fears.
Long-chain triglyceride absorption requires:
- A. Intraluminal bile salts
- B. Mixed micelle formation
- C. Intraluminal trypsin
- D. Intact duodenum
Correct Answer: B
Rationale: Mixed micelle formation: The absorption of long-chain triglycerides requires bile salts to form mixed micelles, which facilitate the transport of lipids across the intestinal mucosa.