In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Black ulcers and dependent rubor
- B. Irregular ulcer shapes and severe edema
- C. Absent pedal pulses and shiny skin
- D. Hairless lower extremities and cool feet
Correct Answer: B
Rationale: Venous ulcers are typically irregular in shape and associated with severe edema, while arterial ulcers are more likely to present with absent pulses and cool extremities.
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An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
- A. Monitor dryness of mucous membranes
- B. Check for changes in mentation
- C. Observe color of skin and nailbeds
- D. Note appearance of jugular veins
Correct Answer: B
Rationale: Changes in mentation, skin color, and breathing patterns are key indicators of hypoxia in clients with lung disease.
In normal neonates:
- A. Extracellular fluid volume exceeds intracellular fluid volume
- B. In a term baby, plasma calcium levels exceed that of the mother
- C. Clamping the umbilical cord after cessation of cord pulsations increases the blood volume by 20% in the baby
- D. There are two arteries and one vein in the umbilical cord
Correct Answer: A
Rationale: In neonates, extracellular fluid volume is greater than intracellular fluid volume, reflecting the transition from intrauterine to extrauterine life.
Sudden death in an athlete immediately after forceful blunt trauma to the chest is most likely
- A. commotio cordis
- B. myocardial infarction
- C. lacerated coronary artery
- D. ruptured cardiac tendineae
Correct Answer: A
Rationale: Commotio cordis occurs due to sudden arrhythmias triggered by chest trauma during a vulnerable phase of the cardiac cycle.
When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
- A. A reduced white blood cell count
- B. A decreased platelet count
- C. Shallow respirations
- D. Tachypnea
Correct Answer: D
Rationale: Tachypnea is a compensatory mechanism in metabolic acidosis to help expel excess carbon dioxide and correct the acid-base imbalance.
Which is the most common causative agent of bacterial endocarditis?
- A. Staphylococcus albus
- B. Streptococcus hemolyticus
- C. Staphylococcus albicans
- D. Streptococcus viridans
Correct Answer: D
Rationale: S. viridans is the most common causative agent in bacterial (infective) endocarditis.