Nokea
A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
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A client post-appendectomy reports shoulder pain on the second postoperative day. The nurse should suspect which complication?
- A. Pneumonia.
- B. Subdiaphragmatic abscess.
- C. Deep vein thrombosis.
- D. Wound infection.
Correct Answer: B
Rationale: Shoulder pain post-appendectomy may indicate a subdiaphragmatic abscess due to referred pain from diaphragmatic irritation. Pneumonia, thrombosis, and wound infection typically present with other symptoms. CN: Physiological adaptation; CL: Analyze
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?
- A. Avoid showering for 48 hours after surgery.
- B. Return to work within 1 week.
- C. Leave dressings in place until you see the surgeon at the postoperative visit.
- D. Use acetaminophen (Tylenol) to control any fever.
Correct Answer: B
Rationale: Returning to work within 1 week (B) is reasonable for laparoscopic cholecystectomy, depending on recovery. Showering is typically allowed after 24-48 hours (A is incorrect). Dressings can often be removed sooner (C), and acetaminophen is for pain, not fever control (D).
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
The nurse is caring for a client interested in pre-exposure prophylaxis for human immunodeficiency virus (HIV). Which prescription would the nurse anticipate?
- A. Voriconazole
- B. Tenofovir-emtricitabine
- C. Raloxifene
- D. Lurasidone
Correct Answer: B
Rationale: Tenofovir-emtricitabine (Truvada) is approved for pre-exposure prophylaxis (PrEP) to prevent HIV infection in high-risk individuals. Choice A (voriconazole) is an antifungal, Choice C (raloxifene) is for osteoporosis, and Choice D (lurasidone) is an antipsychotic.