Nokea
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.
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A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
- A. The urethral orifice is assessed by separating the labia minora.
- B. The cervix should be palpated for size.
- C. The vagina should be inspected without a speculum.
- D. The clitoris should be massaged during examination.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The urethral orifice is located between the clitoris and vaginal opening, so separating the labia minora is necessary to assess it. This step ensures proper assessment of the urinary system and helps detect any abnormalities.
Summary of Incorrect Choices:
B: Palpating the cervix for size is not a standard part of a gynecological examination; it may cause discomfort and is unnecessary unless indicated for specific medical reasons.
C: Inspecting the vagina without a speculum is not recommended as it may not provide a clear view of the vaginal walls and cervix, potentially missing important findings.
D: Massaging the clitoris is not a part of a gynecological examination and is inappropriate; it may be uncomfortable for the patient and is not relevant to the assessment.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
- A. Take the medication early in the day.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication only when blood pressure is high.
Correct Answer: A
Rationale: The correct answer is A: Take the medication early in the day. Hydrochlorothiazide is a diuretic that increases urine production, which can cause frequent urination. Taking it early helps prevent nighttime urination, promoting better sleep. Taking it with food may reduce gastrointestinal upset. Taking it only when blood pressure is high is incorrect, as it should be taken regularly to maintain consistent blood pressure control. Bedtime dosing may lead to nocturnal diuresis and disturb sleep. The other choices are irrelevant or incorrect in the context of hydrochlorothiazide administration.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through direct contact with infected body fluids.
- B. It is transmitted through casual contact.
- C. It is transmitted through airborne droplets.
- D. It is only transmitted through sexual contact.
Correct Answer: A
Rationale: The correct answer is A because HIV is primarily transmitted through direct contact with infected body fluids such as blood, semen, vaginal fluids, and breast milk. This includes activities like unprotected sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding. Casual contact (choice B) is not a common mode of transmission, and HIV is not transmitted through airborne droplets (choice C). While sexual contact is a significant mode of transmission, HIV can also be transmitted through other means involving infected body fluids. Thus, option D is incorrect as it is too limiting.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma often spreads to lymph nodes.
- C. Basal cell carcinoma is most common in young adults.
- D. Basal cell carcinoma is curable with chemotherapy.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. This should be included in the educational program because basal cell carcinoma rarely metastasizes. Metastasis is the spread of cancer from the original site to other parts of the body, and in the case of basal cell carcinoma, it tends to remain localized. This information is crucial for patients to understand the prognosis and treatment options.
Explanation of why other choices are incorrect:
B: Basal cell carcinoma often spreads to lymph nodes - This statement is incorrect as basal cell carcinoma typically does not spread to lymph nodes.
C: Basal cell carcinoma is most common in young adults - Basal cell carcinoma is more common in older individuals, typically over the age of 50.
D: Basal cell carcinoma is curable with chemotherapy - While chemotherapy may be a treatment option for some cases of basal cell carcinoma, it is not the primary treatment and not always curative.