Nokea
In a patient with deep vein thrombosis (DVT), which of the following symptoms would be expected?
- A. Chest pain.
- B. Shortness of breath.
- C. Coughing up blood.
- D. Cyanosis.
Correct Answer: B
Rationale: Shortness of breath is a common symptom of deep vein thrombosis (DVT) due to the risk of a pulmonary embolism. DVT occurs when a blood clot forms in a deep vein, usually in the legs. If a portion of the clot breaks loose and travels to the lungs, it can cause a pulmonary embolism, leading to symptoms like shortness of breath. Chest pain is more commonly associated with conditions like a heart attack or pulmonary embolism itself. Coughing up blood is a symptom more indicative of conditions such as pulmonary embolism or lung cancer. Cyanosis, which is a bluish discoloration of the skin or mucous membranes due to poor oxygenation, can be seen in severe cases of pulmonary embolism but is not a typical symptom of DVT.
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A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should assess the client for which of the following complications?
- A. Hypertension.
- B. Hypotension.
- C. Hyperglycemia.
- D. Edema.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is known to increase blood pressure by stimulating red blood cell production. Monitoring for hypertension is crucial to prevent complications such as heart failure or stroke. Choices B, C, and D are incorrect because hypotension, hyperglycemia, and edema are not typically associated with epoetin alfa therapy in clients with chronic renal failure.
During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?
- A. Initiate isolation precautions
- B. Administer an antipyretic
- C. Draw blood cultures
- D. Prepare for lumbar puncture
Correct Answer: A
Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.
How can a nurse best help a client undergoing a bone marrow aspiration and biopsy, along with two upset family members, manage anxiety during the procedure?
- A. Allow the client's family to stay for emotional support.
- B. Accompany the client silently.
- C. Encourage the client to take slow, deep breaths to promote relaxation.
- D. Provide the client an opportunity to verbalize emotions.
Correct Answer: C
Rationale: Encouraging the client to take slow, deep breaths is an effective way for the nurse to help the client manage anxiety during the bone marrow aspiration and biopsy procedure. Slow, deep breathing can promote relaxation and help reduce anxiety levels. Choice A, allowing the client's family to stay for emotional support, may provide comfort but does not address a direct intervention to help manage anxiety. Choice B, staying with the client silently, may not actively help the client address their anxiety. Choice D, allowing the client to express feelings, is important but may not directly address anxiety management during the procedure.
What is a priority goal for the diabetic client who is taking insulin and experiencing nausea and vomiting from a viral illness or influenza?
- A. Ensuring adequate food intake.
- B. Managing personal health.
- C. Relieving pain.
- D. Increasing physical activity.
Correct Answer: A
Rationale: Ensuring adequate food intake is a priority goal for a diabetic client taking insulin and experiencing nausea and vomiting due to a viral illness or influenza because maintaining proper nutrition is essential to prevent complications such as ketoacidosis. During illness, it is crucial for diabetic individuals to continue to consume appropriate amounts of food to maintain stable blood sugar levels and prevent hypoglycemia. Managing personal health (choice B) is important but not the priority in this situation. Relieving pain (choice C) may be necessary if present but is not the priority over ensuring food intake. Increasing physical activity (choice D) is not recommended during illness, especially when the individual is experiencing nausea and vomiting.
The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Increased blood pressure.
- C. Cloudy dialysate outflow.
- D. Decreased urine output.
Correct Answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.