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A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is essential for confirming bacterial meningitis by analyzing cerebrospinal fluid, making it the priority diagnostic procedure.
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A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
- A. Encourage continued maintenance of the walking routine.
- B. Advise less weight-bearing to prevent joint destruction.
- C. Recommend walking indoors for improved stability and safety.
- D. Suggest a calcium supplement along with continued walking.
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan?
- A. Eat a diet that is high in protein and vitamins A and C.
- B. Maintain bed rest as much as possible.
- C. Keep legs elevated when sitting or lying down.
- D. Inspect ankles daily for areas of darkening skin.
- E. Apply intermittent cold compresses four times daily.
Correct Answer: A,C,D
Rationale: A high-protein diet with vitamins A and C, leg elevation, and daily ankle inspections promote healing and monitor complications in venous leg ulcers.
An obese client with emphysema, who smokes at least a pack of cigarettes daily, is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan?
- A. Guidelines for oxygen use.
- B. Approaches to conserve energy.
- C. Strategies for smoking cessation.
- D. Methods for weight loss.
Correct Answer: A
Rationale: Correct oxygen use guidelines are critical to ensure safety and efficacy in managing emphysema.
A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.