Nokea
Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.
- A. Ask the client to open and close the hand until the skin blanches.
- B. Palpate the ulnar and radial pulses and apply pressure to both arteries.
- C. Observe the hand for color.
- D. Release the ulnar artery while maintaining pressure on the radial artery.
Correct Answer: A,B,D,C
Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.
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The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:
- A. Emphysema
- B. Pneumonia
- C. Tuberculosis
- D. A lung tumor
Correct Answer: A
Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
Which diet is associated with an increased risk of colorectal cancer?
- A. Low protein, complex carbohydrates
- B. High protein, simple carbohydrates
- C. High fat, refined carbohydrates
- D. Low carbohydrates, complex proteins
Correct Answer: C
Rationale: A diet high in fat and refined carbohydrates increases the risk of colorectal cancer due to prolonged intestinal transit time and exposure to carcinogenic metabolites.
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the Coumadin dosage
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of neurological assessments
Correct Answer: A
Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.