Nokea
Clients who take iron preparations should be warned of the possible side effects, which might include:
- A. dizziness and orthostatic hypotension
- B. nausea, vomiting, diarrhea or constipation, and stomach cramps
- C. drowsiness, lethargy, and fatigue
- D. neuropathy and tingling in the extremities
Correct Answer: B
Rationale: Iron supplements commonly cause gastrointestinal side effects like nausea, vomiting, diarrhea, constipation, and stomach cramps, requiring client education.
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Assessment of the client with an arteriovenous fistula for hemodialysis should include:
- A. inspection for visible pulsation.
- B. palpation of thrill.
- C. percussion for dullness.
- D. auscultation of blood pressure.
Correct Answer: B
Rationale: Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.
When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. warm, dry skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth.
Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct Answer: C
Rationale: Acute Pain is most appropriate for the client experiencing acute pancreatitis, as pancreatitis causes severe abdominal pain due to inflammation and autodigestion of the pancreas.