Nokea
A nurse is caring for a client with a history of an abdominal aortic aneurysm. Which of the following assessment findings requires immediate intervention?
- A. Back pain
- B. Absent peripheral pulses
- C. Decreased urine output
- D. Nausea and vomiting
Correct Answer: B
Rationale: An AAA can rupture absent peripheral pulses signal dissection or clot, cutting flow, a surgical emergency needing instant action per ABCs. Back pain hints at expansion, urgent but less acute. Urine drop or nausea follows, not leads. Nurses jump on pulselessness, anticipating OR prep, a life-or-limb save in this ticking vascular bomb.
You may also like to solve these questions
Why are endothelial cells in particular sensitive to the damage caused by high plasma glucose levels?
- A. Endothelial cells have a high metabolic activity
- B. Endothelial cells cannot regulate the glucose uptake
- C. Endothelial cells have a low level of antioxidants
- D. All statements provided above are correct
Correct Answer: B
Rationale: Endothelial cells drown in glucose no uptake brakes, high sugar slams them, not just metabolism or low shields. A chronic vessel weak spot nurses watch this sugar soak.
Self-management is an important principle in optimal management and prevention of exacerbation. In order for the patient to self-manage appropriately, which of the following is not required?
- A. Understanding of the pathophysiology of disease, nature of inflammation and bronchoconstriction and trigger avoidance
- B. Education on medication compliance, use of devices and correct inhalation technique, as well as when to increase dosage
- C. Assessment by multidisciplinary team to address additional health concerns
- D. Development of an action plan in knowledge on when to implement and when to seek assistance
Correct Answer: C
Rationale: Asthma self-rule needs know-how pathology, meds, triggers, action plans not a full team probe. That's extra, not must-have; core's patient-led. Nurses train this, a chronic solo skill.
The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breathe and the nurse's rapid assessment reveals that the patient's jugular veins are distended. The nurse should suspect the development of what oncologic emergency?
- A. Increased intracranial pressure
- B. Superior vena cava syndrome (SVCS)
- C. Spinal cord compression
- D. Metastatic tumor of the neck
Correct Answer: B
Rationale: Dyspnea plus distended jugulars scream SVCS breast cancer's mets can squeeze the vena cava, blocking venous return from the head and chest. It's an oncology emergency, fast-tracking to edema and airway issues if unchecked. Intracranial pressure needs brain involvement less likely here. Spinal compression hits legs and bladder, not breathing. Neck tumors might press locally, but SVCS fits this picture. Nurses jump on this, pushing for steroids or stenting, knowing seconds count.
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate?
- A. Crush the medications if the client cannot swallow them.
- B. Give one medication at a time with a full glass of water.
- C. No special precautions are needed for these medications.
- D. Wear personal protective equipment when handling the medications.
Correct Answer: D
Rationale: Oral chemotherapy drugs, like their IV counterparts, are hazardous due to their cytotoxic properties, posing risks to healthcare workers through skin contact or inhalation during handling. The most appropriate action is for the nurse to wear personal protective equipment (PPE), such as gloves, to minimize exposure, aligning with oncology safety standards. Crushing these medications is contraindicated, as it increases the risk of aerosolizing toxic particles, endangering both nurse and client many are labeled do not crush.' Giving one at a time with water isn't necessary unless specified and doesn't address safety. Assuming no precautions are needed ignores the drugs' hazardous nature, risking occupational exposure. Using PPE ensures safe administration, protects the nurse's health, and maintains the medication's integrity, reflecting best practices in cancer care where handling precautions are non-negotiable.
The nurse is reviewing laboratory values for a client. Which of the following lab values should the nurse address immediately?
- A. Potassium 5.9 mmol/L
- B. Phosphorus 5.1 mg/dL
- C. Creatinine 6.2 mg/dL
- D. Sodium 147 mEq/L
Correct Answer: A
Rationale: Potassium 5.9 mmol/L above 5.5 sparks hyperkalemia, risking arrhythmias, a now-or-never fix over phosphorus's mild bump (3.0-4.5 normal). Creatinine's renal cry waits; sodium's high but tolerable. Nurses jump on potassium, anticipating ECG or kayexalate, a heart-stopping lab in this urgent sweep.