Nokea
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
- A. Oral itching after eating bananas
- B. Swelling of the eyes and mouth
- C. Difficulty in breathing
- D. Swelling and itching of the hands
Correct Answer: D
Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
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The nurse is caring for a client with suspected endometrial cancer.
- A. Frothy vaginal discharge
- B. Thick, white vaginal discharge
- C. Purulent vaginal discharge
- D. Watery vaginal discharge
Correct Answer: D
Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which can manifest as watery vaginal discharge. Frothy discharge is more typical of trichomoniasis, thick white discharge suggests a yeast infection, and purulent discharge indicates infection, none of which are primary symptoms of endometrial cancer.
The nurse is caring for a client with a suspected fractured hip. Which intervention is most appropriate?
- A. Encourage ambulation to promote healing.
- B. Apply a warm compress to reduce pain.
- C. Immobilize the leg to prevent further injury.
- D. Administer aspirin for pain relief.
Correct Answer: C
Rationale: Immobilizing the leg prevents further injury and displacement in a suspected hip fracture. Amb
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
- A. Respiratory depression
- B. Autonomic dysreflexia
- C. Pressure ulcers
- D. Deep vein thrombosis
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?
- A. Norepinephrine (Levophed)
- B. Dobutamine (Dobutrex)
- C. Propranolol (Inderal)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Norepinephrine's side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. Dobutamine's side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. Propranolol's side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
- A. The tail of the pancreas
- B. The head of the pancreas
- C. The body of the pancreas
- D. The entire pancreas
Correct Answer: B
Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.