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A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make?
- A. I will need to apply electrodes to your chest and extremities.
- B. You may feel some discomfort during the procedure.
- C. The procedure will take about an hour.
- D. We need to monitor your heart rate continuously after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Applying electrodes to the chest and extremities is necessary for a complete ECG recording. Electrodes are placed strategically to capture electrical activity of the heart. This statement informs the client about the procedure and ensures accurate results. Other options are incorrect because discomfort during the procedure is subjective and not guaranteed (B), an ECG typically takes only a few minutes, not an hour (C), and continuous heart rate monitoring is not required post-procedure unless indicated by the results (D).
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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.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching?
- A. Postcoital bleeding may occur.
- B. A pelvic ultrasound is required for diagnosis.
- C. Cervical polyps usually resolve without treatment.
- D. Cervical polyps are rarely associated with cancer.
Correct Answer: A
Rationale: The correct answer is A: Postcoital bleeding may occur. This information is essential to include in teaching about cervical polyps because it is a common symptom associated with this condition. Cervical polyps are benign growths on the cervix that can cause bleeding, especially after intercourse. It is crucial for the client to be aware of this symptom to monitor for any abnormal bleeding and seek medical attention if necessary.
Option B is incorrect because a pelvic ultrasound is not always required for diagnosing cervical polyps; they can often be diagnosed through a pelvic exam. Option C is incorrect because not all cervical polyps resolve on their own and may require treatment if symptomatic. Option D is incorrect because while cervical polyps are usually benign, they can be associated with an increased risk of cervical cancer in some cases.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Abdominal cramps and diarrhea
- B. Persistent cough and chest pain
- C. Flu-like symptoms and night sweats
- D. Severe fatigue and weight loss
Correct Answer: C
Rationale: The correct answer is C: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often resemble flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This occurs because the virus is rapidly replicating in the body and the immune system is reacting to it. The other choices, abdominal cramps and diarrhea (A), persistent cough and chest pain (B), and severe fatigue and weight loss (D), are more commonly associated with later stages of HIV infection or other conditions. Therefore, the nurse should include flu-like symptoms and night sweats in the explanation of initial symptoms to accurately inform the client.
A client reports skin dryness, redness, and scaling after radiation. What should the nurse advise?
- A. Apply hydrating lotions.
- B. Scrub the area vigorously.
- C. Cover the area with adhesive bandages.
- D. Avoid moisturizing the skin.
Correct Answer: A
Rationale: The correct answer is A: Apply hydrating lotions. After radiation, skin can become dry and irritated. Hydrating lotions help to moisturize the skin and reduce dryness, redness, and scaling. They provide a protective barrier and promote skin healing. Advising the client to apply hydrating lotions is essential in maintaining skin integrity post-radiation.
Choice B: Scrubbing the area vigorously can further damage the skin and exacerbate irritation.
Choice C: Covering the area with adhesive bandages can trap moisture and lead to skin maceration.
Choice D: Avoiding moisturizing the skin can worsen dryness and discomfort.