Nokea
A nurse is admitting a client with a history of duodenal ulcer. To determine if the client's current symptoms are related to this information, the nurse should assess the client for which manifestations of a duodenal ulcer?
- A. Pain relieved by food intake
- B. Pain radiating down the right arm
- C. Nausea and vomiting
- D. Weight loss
Correct Answer: A
Rationale: Pain relief after eating is characteristic of duodenal ulcers as food neutralizes gastric acid temporarily.
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A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurological disorders should the nurse suspect?
- A. Embolic stroke
- B. Thrombotic stroke
- C. Transient ischemic attack (TIA)
- D. Hemorrhagic stroke
Correct Answer: D
Rationale: The sudden severe headache followed by seizure and unresponsiveness with elevated BP suggests hemorrhagic stroke.
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?
- A. Metabolic alkalosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: Low pH with low HCO3 indicates metabolic acidosis with appropriate respiratory compensation.
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?
- A. These tests will enable the provider to determine the heart structure and mobility of the heart valves.
- B. Cardiac enzymes will identify the location of the MI.
- C. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion.
- D. These tests help determine the degree of damage to the heart tissues.
Correct Answer: D
Rationale: Cardiac enzymes (like troponin) indicate myocardial cell death and help quantify infarct size.