Nokea
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
- A. Urinary output less than intake
- B. Bruising at the insertion site
- C. Slurred speech and confusion
- D. Discomfort in the left leg
Correct Answer: C
Rationale: Slurred speech and confusion may indicate a neurological complication, such as a stroke, which requires immediate intervention.
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An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor?
- A. Serum electrolytes
- B. Neutrophils and eosinophils
- C. Serum iron and ferritin
- D. Platelet count and hematocrit
Correct Answer: C
Rationale: Serum iron and ferritin levels should be monitored because they are indicators of iron deficiency, which is a common cause of restless leg syndrome.
An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Sensation in feet and legs
- C. Skin condition of lower extremities
- D. Visual acuity
Correct Answer: B
Rationale: These assessments are crucial for detecting complications such as neuropathy, nephropathy, and retinopathy.
Which drug should not be used to control secondary hypertension in a sexually active adolescent female who uses intermittent birth control?
- A. Beta blockers
- B. Calcium channel blockers
- C. ACE inhibitors
- D. Diuretics
Correct Answer: C
Rationale: ACE inhibitors and angiotensin II receptor blockers are teratogenic and should be avoided in sexually active adolescents using birth control.
Concerning tetanus:
- A. The infection is usually fatal
- B. The muscle spasms are often localized
- C. Immunization confers lifelong immunity
- D. Incubation period is usually weeks
Correct Answer: C
Rationale: Immunization with the tetanus toxoid provides long-lasting immunity, though booster shots are recommended to maintain protection.
The typical radiologic configuration in tetralogy of Fallot as seen in the anteroposterior view consists of all the following EXCEPT
- A. normal heart size
- B. some elevation of the cardiac apex
- C. convexity in the region of the main pulmonary artery
- D. right-sided aortic arch
Correct Answer: A
Rationale: Normal heart size is not typical in tetralogy of Fallot.