Nokea
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
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Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
- A. The support available to assist the client at home.
- B. The distance the client lives from the hospital.
- C. The client's ability to do home blood pressure monitoring.
- D. The client's knowledge of the causes of lung cancer.
Correct Answer: A
Rationale: Home support is critical post-lobectomy to assist with recovery, medication adherence, and monitoring complications. Distance from the hospital, blood pressure monitoring, and knowledge of cancer causes are less immediate priorities.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive 4 year old child. Which therapeutic action should the nurse take?
- A. Draw a "magic circle" on the area before the injection.
- B. Have another nurse hold down the child.
- C. Apply EMLA cream to the area immediately before the injection.
- D. Administer the medication right after the child's nap.
Correct Answer: D
Rationale: Administering after a nap can reduce anxiety and discomfort in a child, as they are likely to be calmer.
The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These traffic control measures are designed to:
- A. Protect the privacy of clients.
- B. Prevent electrical sparks that could ignite the anesthetic gases.
- C. Separate the family from the surgical team to prevent distraction of the client.
- D. Provide for an aseptic environment to prevent infection.
Correct Answer: D
Rationale: Restricting access to the operating room maintains an aseptic environment, reducing the risk of surgical site infections by limiting contamination.
A client with cancer is admitted with suspected disseminated intravascular coagulation (DIC). Which laboratory finding supports this diagnosis?
- A. Prolonged prothrombin time (PT).
- B. Elevated hemoglobin.
- C. Normal platelet count.
- D. Decreased D-dimer.
Correct Answer: A
Rationale: DIC causes abnormal clotting and bleeding, leading to a prolonged prothrombin time (PT) due to consumption of clotting factors, supporting the diagnosis.