Nokea
An 82-year-old female complains of generalized fatigue and has new onset of urinary incontinence as well as anorexia, hyperventilation, and low-grade fever. The nurse anticipates that the client will be evaluated for which of the following?
- A. Diabetes mellitus.
- B. Bladder cancer.
- C. Urinary tract infection.
- D. Influenza.
Correct Answer: C
Rationale: Symptoms of fatigue, urinary incontinence, anorexia, and low-grade fever in an elderly female are classic for a urinary tract infection (C). Diabetes (A), bladder cancer (B), and influenza (D) are less likely to present with this combination of symptoms.
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A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- A. Constipation
- B. Hyperphosphatemia
- C. Hypomagnesemia
- D. Diarrhea
Correct Answer: A
Rationale: Calcium carbonate can cause constipation, a common side effect, due to its effect on gastrointestinal motility.
A client with bipolar disorder is taking lithium to control symptoms. Which of the following statements indicates the need for further education?
- A. I need to have regular tests for thyroid function.
- B. Once I'm stabilized, I won't need further testing.
- C. I should avoid taking ibuprofen.
- D. It's important for me to avoid dehydration.
Correct Answer: B
Rationale: Lithium requires ongoing monitoring (B is incorrect), as levels and side effects need regular checks. Thyroid tests (A), avoiding ibuprofen (C), and hydration (D) are correct.
The priority nursing intervention for a client with sickle cell crisis is to
- A. administer pain medication.
- B. administer packed RBC.
- C. administer oxygen.
- D. administer IV fluids.
Correct Answer: D
Rationale: IV fluids are the priority in sickle cell crisis to reduce blood viscosity, promote perfusion, and prevent organ damage.
During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.
- A. The client is sweating and wringing his hands.
- B. The client states, 'I am having second thoughts about my surgery.'
- C. The client reports he has lost 6 pounds in the last 2 months.
- D. The client's blood pressure is 128/82.
- E. The client rates his pain as a 3 on a scale of 0-10.
Correct Answer: B,C,E
Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).