Nokea
Arterial ulcers are best described as ulcers that:
- A. Are smooth in texture
- B. Have irregular borders
- C. Are cool to touch
- D. Are painful to touch
Correct Answer: D
Rationale: Arterial ulcers are typically painful due to poor blood flow and tissue ischemia.
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The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: B
Rationale: Confusion and restlessness may indicate cerebral hypoxia or other serious complications post-CABG, requiring immediate reporting.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.
- A. Abduction and adduction
- B. Hyperextension
- C. Supination and pronation
- D. Flexion and extension
- E. Rotation
Correct Answer: C,D
Rationale: Elbow ROM includes supination/pronation (C) and flexion/extension (D). Abduction/adduction (A), hyperextension (B), and rotation (E) are not applicable to the elbow joint.
Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- A. Thiamine
- B. Niacin
- C. Pyridoxine
- D. Riboflavin
Correct Answer: C
Rationale: Pyridoxine (vitamin B6) is given with isoniazid to prevent peripheral neuropathy, a potential side effect of the medication.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: Cushing's disease causes immunosuppression, increasing infection risk, warranting a private room.