Nokea
A nurse is explaining DIC to a client with septic shock. What should the nurse say?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is due to a vitamin K deficiency.
- C. DIC is caused by bone marrow suppression.
- D. DIC results from an underactive clotting system.
Correct Answer: A
Rationale: The correct answer is A because Disseminated Intravascular Coagulation (DIC) is characterized by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade leading to the formation of microthrombi. This process consumes clotting factors like fibrinogen, leading to bleeding tendencies. Vitamin K deficiency (B) primarily affects the production of clotting factors, but it is not the direct cause of DIC. Bone marrow suppression (C) and an underactive clotting system (D) are not accurate explanations for DIC.
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A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
- A. Melanoma
- B. Squamous cell carcinoma
- C. Basal cell carcinoma
- D. Kaposi's sarcoma
Correct Answer: C
Rationale: The correct answer is C: Basal cell carcinoma. Basal cell carcinoma typically presents as a raised, flesh-colored lesion with pearly white borders. This type of skin cancer is the most common and is usually slow-growing with low metastatic potential. It is often found on sun-exposed areas such as the face, neck, and chest. Melanoma (A) is characterized by asymmetry, irregular borders, varied color, and a diameter larger than 6mm. Squamous cell carcinoma (B) is usually a firm, red nodule or a flat lesion with a scaly crust. Kaposi's sarcoma (D) typically presents as purple or blue-black patches or nodules on the skin.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
- A. Reposition the client
- B. Check the chest tube for kinks
- C. Increase the suction pressure
- D. Administer pain medication
Correct Answer: A
Rationale: Repositioning the client can help alleviate chest burning caused by the chest tube.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Flat T wave
- B. Prominent U wave
- C. ST elevation
- D. Wide QRS complex
Correct Answer: B
Rationale: The correct answer is B: Prominent U wave. Hypokalemia, or low potassium levels, can cause the U wave to become more prominent on an EKG strip. This is due to delayed repolarization of the ventricles. A flat T wave (choice A) is typically associated with ischemia or infarction. ST elevation (choice C) is often seen in conditions like myocardial infarction. A wide QRS complex (choice D) is indicative of conduction abnormalities. Choices E, F, and G are not relevant to the interpretation of hypokalemia on an EKG strip.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Abnormally prominent U wave
- B. Tachycardia
- C. Flattened P wave
- D. Prolonged PR interval
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.