Nokea
A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:
- A. nothing related to the blood transfusion.
- B. graft-versus-host disease (GVHD).
- C. myelosuppression.
- D. an allergic response to a recent medication.
Correct Answer: B
Rationale: GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient.
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A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?
- A. Loss of hearing acuity
- B. A problem with balance
- C. A problem with distant hearing
- D. A problem discriminating high-pitched and low-pitched sounds
Correct Answer: B
Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.
What is a chemical reaction between drugs before their administration or absorption known as?
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct Answer: A
Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.
A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
- A. By checking the client's urine for blood
- B. By checking the client's stool for blood
- C. By checking the client's urine for a decrease in output
- D. By checking the client's bowel movements for diarrhea
Correct Answer: B
Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?
- A. Asking the client to raise their eyebrows and looking for symmetry
- B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
- C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
- D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear
Correct Answer: D
Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?
- A. The procedure typically takes 10 to 30 minutes.
- B. She may need to drink fluids before the test and may not void until the test has been completed.
- C. A probe coated with gel will be inserted into the vagina.
- D. She will be positioned on her back, with her head elevated and turned slightly to one side.
Correct Answer: B
Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.