Nokea
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
- A. Monitor dryness of mucous membranes
- B. Check for changes in mentation
- C. Observe color of skin and nailbeds
- D. Note appearance of jugular veins
Correct Answer: B
Rationale: Changes in mentation, skin color, and breathing patterns are key indicators of hypoxia in clients with lung disease.
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Which clinical manifestation is included in toxic shock syndrome?
- A. Severe hypertension
- B. Subnormal temperature
- C. Erythematous macular rash
- D. Papular rash over extremities
Correct Answer: C
Rationale: One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
The most common site of osteosarcoma is:
- A. Femur
- B. Humerus
- C. Pelvis
- D. Skull
Correct Answer: A
Rationale: Osteosarcoma most commonly occurs in the long bones, particularly the femur, near the growth plates in children and adolescents.
Mitral valve prolapse
- A. Occurs in congenital myxomatous valves
- B. Need a Sx
- C. Rare cause of MR
- D. Need prophylactic antibiotics
Correct Answer: A
Rationale: Mitral valve prolapse often occurs in congenital myxomatous valves.
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
- A. Document negative results in the client's medical record
- B. Repeat the test immediately on the opposite forearm
- C. Notify the healthcare provider for further evaluation
- D. Schedule the worker for a chest X-ray
Correct Answer: A
Rationale: Erythema without induration is not considered a positive result. Documentation of negative findings is appropriate.
The primary care pediatric nurse practitioner is performing a well child examination on a school-age child who had complete repair of a tetralogy of Fallot (TOF) defect in infancy. What is important in this child's health maintenance regime?
- A. Cardiology clearance for sports participation
- B. Restriction of physical activity to avoid pulmonary complications
- C. Sub-acute bacterial endocarditis prophylaxis precautions
- D. Teaching about management of hypercyanotic episodes
Correct Answer: A
Rationale: Children who have had TOF repair must be cleared by cardiology before participation in sports.