Nokea
A client with jaundice has which skin color?
- A. Pale
- B. Ruddy
- C. Yellow
- D. Pink
Correct Answer: C
Rationale: Jaundice causes yellow skin due to bilirubin accumulation, unlike the other color descriptions.
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When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. warm, dry skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth.
Clients who take iron preparations should be warned of the possible side effects, which might include:
- A. dizziness and orthostatic hypotension
- B. nausea, vomiting, diarrhea or constipation, and stomach cramps
- C. drowsiness, lethargy, and fatigue
- D. neuropathy and tingling in the extremities
Correct Answer: B
Rationale: Iron supplements commonly cause gastrointestinal side effects like nausea, vomiting, diarrhea, constipation, and stomach cramps, requiring client education.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. within normal limits, so a weight-reduction diet is unnecessary.
- B. lower than normal, so education about nutrient-dense foods is needed.
- C. indicating obesity because the BMI is 35.
- D. indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client's BMI, activity status, and energy requirements.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
- A. Ca
- B. K
- C. Na
- D. Cl
Correct Answer: B
Rationale: A potassium level of 2.0 mEq/L is critically low (normal 3.5-5.5 mEq/L), risking cardiac arrhythmias, and should be reported immediately.