Nokea
A nurse cares for a group of clients who are experiencing symptoms of withdrawal from alcohol. Which finding requires immediate follow-up?
- A. Tremors
- B. Inability to sleep
- C. Hematemesis
- D. Transient hallucinations
Correct Answer: C
Rationale: The client needs to be seen immediately. Hematemesis is a symptom of rupture of associated esophageal varices. The mortality rate with acute bleeding is 10% to 40% and is related to failure to control a bleeding episode.
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Which condition is a risk factor for pulmonary embolism?
- A. Dehydration
- B. Hypotension
- C. Bradycardia
- D. Fever
Correct Answer: A
Rationale: Dehydration increases blood viscosity, promoting clot formation and pulmonary embolism risk, more than hypotension, bradycardia, or fever.
Which condition increases the work of breathing?
- A. Pneumonia
- B. Hypertension
- C. Anemia
- D. Diabetes
Correct Answer: A
Rationale: Pneumonia causes lung inflammation and consolidation, increasing resistance and the work of breathing, unlike hypertension, anemia, or diabetes, which affect circulation or metabolism.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings, and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
- A. The client is receiving formula at room temperature
- B. The feedings infuse at a slow, continuous drip over 8 hr each night
- C. The client’s caregiver washes out the feeding bag with warm water once every 24 hr
- D. The client’s caregiver flushes the tubing with water before and after administering medications.
Correct Answer: C
Rationale: The client’s caregiver washes out the feeding bag with warm water once every 24 hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination.
A nurse is assessing an older client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select ONE that does not apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
Correct Answer: A
Rationale: Pupil clarity, Visual fields, Visual acuity.
A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?
- A. Bacteria
- B. Parasites
- C. Steatorrhea
- D. Blood
Correct Answer: D
Rationale: A stool test for occult blood detects hidden blood, indicating potential GI bleeding. Bacteria (A) and parasites (B) require different tests. Steatorrhea (C) is assessed via a fecal fat test.