Nokea
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
- A. Determine if the client has also experienced breast tenderness and weight gain.
- B. Encourage the client to begin a regular, daily program of walking and exercise.
- C. Advise the client to notify the healthcare provider for immediate medical attention.
- D. Tell the client to stop taking the medication for a week to see if symptoms subside.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?
- A. Report the findings to the surgeon.
- B. Irrigate the indwelling urinary catheter.
- C. Apply manual pressure to the bladder.
- D. Increase the IV flow rate for 15 minutes.
Correct Answer: A
Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
- A. Use a laryngoscope to check for a foreign body lodged in the airway.
- B. Reposition the head to ensure that the airway is properly opened.
- C. Turn the client to the side and administer three back blows.
- D. Perform a finger sweep of the mouth to clear any obstructions.
Correct Answer: B
Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.
Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?
- A. Numbness, tingling, and cramps in the extremities.
- B. Headache, diaphoresis, and palpitations.
- C. Cyanosis, fever, and classic signs of shock.
- D. Nausea, vomiting, and muscular weakness.
Correct Answer: B
Rationale: Correct. Pheochromocytoma is a catecholamine-secreting non-cancerous tumor of the adrenal medulla. The classic triad of symptoms includes headache, diaphoresis (excessive sweating), and palpitations, which result from the overproduction of catecholamines like epinephrine and norepinephrine. Numbness, tingling, and cramps in the extremities (Option A) are not characteristic of pheochromocytoma. Cyanosis, fever, and classic signs of shock (Option C) are not typical symptoms of this condition. Nausea, vomiting, and muscular weakness (Option D) are not commonly associated with pheochromocytoma.
During an interview with a client planning elective surgery, the client asks the nurse, 'What is the advantage of having a preferred provider organization insurance plan?' Which response is best for the nurse to provide?
- A. Neither plan allows the selection of healthcare providers or hospitals.
- B. There are fewer healthcare providers to choose from than in an HMO plan.
- C. An individual may select healthcare providers from outside of the PPO network.
- D. An individual can become a member of a PPO without belonging to a group.
Correct Answer: C
Rationale: The best response for the nurse to provide is option C, as it highlights a key advantage of a preferred provider organization (PPO) insurance plan. By stating that an individual may select healthcare providers from outside of the PPO network, the nurse emphasizes the flexibility and freedom of choice that PPO plans offer. This feature allows individuals to seek care from providers who are not part of the PPO network, albeit at a higher cost. Option A is incorrect because both PPO and HMO plans allow the selection of healthcare providers, although with different restrictions. Option B is incorrect as PPO plans typically offer a larger selection of healthcare providers compared to HMO plans. Option D is incorrect as membership in a PPO usually requires affiliation with a group, such as through employment or membership in an organization.
What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?
- A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
- B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
- C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
- D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Correct Answer: C
Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.