Nokea
An adult is admitted in diabetic ketoacidosis. What observation by the nurse is consistent with the diagnosis?
- A. Deep respirations
- B. Foul breath
- C. Constipation
- D. Red rash
Correct Answer: A
Rationale: Deep, rapid (Kussmaul) respirations are a compensatory mechanism in diabetic ketoacidosis to eliminate excess CO2, correcting acidosis.
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An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
- A. Obtain an ECG
- B. Check blood gasses
- C. Dress wounds
- D. Check electrolytes
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.
The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
- A. If the client signed the proper forms, the client is committed to the study.
- B. Persons who have signed up for a study may opt out of the study at any time.
- C. The person should discuss his/her concerns with the researchers.
- D. Inform the client that there are drugs that can control nausea.
Correct Answer: B
Rationale: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
A client asks the home care nurse to look at the bruises on her arms and legs. The woman also tells the nurse that her gums bleed when she uses dental floss or brushes her teeth. The client is taking all of the following medications. Which is most likely related to the client's symptoms?
- A. Metformin (Glucophage)
- B. Estrogen (Premarin)
- C. Atenolol (Tenormin)
- D. Ibuprofen (Motrin)
Correct Answer: D
Rationale: Ibuprofen, an NSAID, can inhibit platelet function, causing bruising and bleeding gums. Other medications are less likely to cause these symptoms.
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
- A. Report it immediately to the charge nurse or the physician
- B. Record the finding and continue to observe
- C. Immediately apply pressure to the operative site
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings suggests to the nurse that the infant has fetal alcohol syndrome?
- A. Growth retardation is evident
- B. Multiple anomalies are identified
- C. Cranial facial abnormalities are noted
- D. Prune belly syndrome is suspected
Correct Answer: C
Rationale: Cranial facial abnormalities are noted. Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.