Nokea
A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema.
On admission of this patient, which of the following should be assessed first?
- A. blood pressure
- B. skin breakdown
- C. serum potassium
- D. urine output
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.
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The nurse is preparing to discharge a client who is receiving Nardil (phenelzine). The nurse should tell the client to:
- A. Wear protective clothing and sunglasses outside.
- B. Avoid medications containing pseudoephedrine.
- C. Drink six to eight glasses of water a day.
- D. Avoid foods that are high in purine.
Correct Answer: B
Rationale: Drug interactions between an MAOI and pseudoephedrine can result in hypertensive crisis. Answer A refers to the client receiving antipsychotic medications such as Thorazine, so it is incorrect. Answers C and D do not apply to MAOIs, so they are incorrect.
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
- A. Weekly Z-track injections are required for control.
- B. Daily intramuscular injections are required for control.
- C. Intramuscular injections once a month will maintain control.
- D. Oral tablets of vitamin B12 taken daily will keep the symptoms under control.
Correct Answer: C
Rationale: Monthly B12 injections maintain control in pernicious anemia due to absorption deficits.
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
- A. Alcohol promoted the formation of calculi in the cystic duct.
- B. The pancreas is stimulated to secrete more insulin than it can immediately produce.
- C. The alcohol alters the composition of enzymes so they are capable of damaging the pancreas.
- D. Alcohol increases enzyme secretion and pancreatic duct pressure and causes backflow of enzymes into the pancreas.
Correct Answer: D
Rationale: Alcohol causes enzyme backflow, leading to pancreatic autodigestion.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (B), increased vaginal discharge (C), and diaphragmatic pressure (D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.
A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night.
- B. Practice monthly self-breast examination.
- C. Reduce stress.
- D. All of the above.
Correct Answer: D
Rationale: All listed actions—adequate sleep, self-breast exams, and stress reduction—contribute to cancer prevention by supporting immune function, early detection, and overall health. Health Promotion and Management