Nokea
A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.
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An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
- A. obtain an order for a stool softener.
- B. administer packed RBCs, if ordered.
- C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
- D. dress venipuncture sites immediately to prevent infection.
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
A diet rich in calcium over a lifetime will decrease the risk of
Heart disease
- A. Osteoporosis
- B. Gout
- C. Rheumatoid Arthritis
Correct Answer: B
Rationale: A diet rich in calcium over a lifetime will decrease the risk of osteoporosis by strengthening bones.
A 4-year-old child with Down syndrome is admitted to the hospital with pneumonia. She has a heart murmur and appears to be in respiratory distress. Her mother asks why her child has a heart murmur. What is the best nursing response?
- A. Because she has pneumonia, her heart is working harder and causes the murmur.'
- B. Heart murmurs come and go in children. It is not a great concern.'
- C. Because of the pneumonia, her ductus arteriosus is functioning again.'
- D. Heart defects are common in children with Down syndrome. Her illness may make the murmur louder.'
Correct Answer: D
Rationale: Congenital heart defects, like ventricular septal defects, are common in Down syndrome, and pneumonia may amplify a murmur due to increased cardiac workload.