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A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
- A. Assess for potential abuse.
- B. Check for diminished sensations.
- C. Document the findings.
- D. Clean and dress the area.
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
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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
The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease?
- A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
- B. A 43-year-old male with a family history of CAD and cholesterol level of 158.
- C. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor).
- D. A 65-year-old female who is obese with an LDL of 188.
Correct Answer: D
Rationale: Obesity and elevated LDL (188) are significant risk factors for coronary artery disease. The other clients have lower-risk profiles due to younger age, smoking cessation, or controlled lipids.
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to:
- A. Sit in an upright position and take a deep breath.'
- B. Hold your abdomen firmly with a pillow and take several deep breaths.'
- C. Tighten your stomach muscles as you inhale and relax them as you exhale.'
- D. Raise your shoulders to expand your chest.'
Correct Answer: B
Rationale: Holding the abdomen with a pillow during deep breathing reduces pain and supports the surgical site post-adrenalectomy.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:
- A. Contact the surgeon to request an order for a narcotic for the pain.
- B. Maintain the client in a recumbent position.
- C. Place the client on nothing-by-mouth (NPO) status.
- D. Apply heat to the abdomen in the area of the pain.
Correct Answer: C
Rationale: The client with acute appendicitis should be placed on NPO status in preparation for surgery to prevent aspiration risk. Narcotics may mask symptoms, a recumbent position is not specific, and heat could worsen inflammation. CN: Physiological adaptation; CL: Synthesize
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
- A. Passage of liquid stool from the stoma.
- B. Occasional presence of undigested food in the effluent.
- C. Absence of drainage from the ileostomy for 6 or more hours.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize