Nokea
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
- A. erythema
- B. leukocytosis
- C. pressurelike pain
- D. swelling
Correct Answer: C
Rationale: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
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When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct Answer: C
Rationale: The maximum flow rate for a nasal cannula is 6 liters/minute to avoid drying nasal passages and discomfort. Higher rates require a mask. Reduction of Risk Potential
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.
Anaphylactic shock is a serious type of blood transfusion reaction.
The pathophysiology of anaphylaxis is
- A. It is treated with adrenalin or epinephrine.
- B. A severe vasoconstriction and profound bronchodilation.
- C. Characterized by presence of rashes all throughout the body.
- D. A profound hypotension due to profound vasodilation and severe bronchoconstriction.
Correct Answer: D
Rationale: Anaphylaxis involves vasodilation and bronchoconstriction, leading to hypotension and respiratory distress.
During a home visit, the nurse observes a man who is recovering from a left total hip replacement. Which observation indicates that the client understands his care?
- A. He is sitting in a soft, overstuffed easy chair.
- B. He bends over to pat his cat.
- C. He crosses his legs when sitting.
- D. He holds the cane in his right hand when walking.
Correct Answer: D
Rationale: Holding the cane in the right hand (opposite the affected left hip) provides support and balance, indicating proper care understanding. Soft chairs, bending, or crossing legs risk hip dislocation.