Nokea
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
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A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse?
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: B
Rationale: A unit of packed red blood cells is approximately 250–300 mL. At 60 mL/hour, 240 mL (close to a unit) takes 240 ÷ 60 = 4 hours.
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
- A. Suction the airway.
- B. Administer oxygen at 6 L/min.
- C. Reposition the client to a lateral position.
- D. Increase I.V. fluids.
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
- A. Decrease in appetite.
- B. Drowsiness.
- C. Spasms of the diaphragm.
- D. Cough and shortness of breath.
Correct Answer: D
Rationale: Cough and shortness of breath are hallmark symptoms of pulmonary toxicity, indicating potential lung damage from chemotherapy and requiring immediate attention.
A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
- A. Avoid heating pads
- B. Not cross her legs
- C. Wear leather shoes
- D. Use iodine on an injured site
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.