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Prioritize them in order of severity.
- A. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating
- B. An 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days
- C. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week
- D. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
Correct Answer: D
Rationale: A pulsating abdominal mass with sudden onset of pain suggests a possible abdominal aortic aneurysm, a life-threatening condition.
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Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)?
- A. Garlic
- B. Fish oil
- C. Valerian
- D. Vitamin E, Astragalus, Ginkgo biloba
Correct Answer: D
Rationale: Herbs like garlic, fish oil, vitamin E, astragalus, and ginkgo biloba can increase bleeding risks and should be avoided before surgery.
Patients with rheumatoid arthritis typically have pain
- A. With activity.
- B. Only upon awakening.
- C. Late in the evening.
- D. All day without remission.
Correct Answer: A
Rationale: RA pain worsens with activity due to joint inflammation.
What is most important to determine when completing Mr. Anderson’s nursing history?
- A. Known allergy to penicillin
- B. Work habits
- C. History of COPD
- D. Sleep and rest habits
Correct Answer: A
Rationale: Penicillin allergy is critical to know before administering antibiotics.
Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse?
- A. Administer oxygen.
- B. Administer bronchodilators.
- C. Administer antianxiety agents.
- D. Use any methods that make the patient more comfortable.
Correct Answer: D
Rationale: Comfort measures tailored to the individual patient’s needs are prioritized in palliative care, ensuring the patient feels supported and comfortable.
While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?
- A. Lethargy
- B. High-grade fever
- C. Weight gain
- D. Dry cough
Correct Answer: A
Rationale: The correct answer is A: Lethargy. In pulmonary tuberculosis, lethargy is common due to systemic symptoms like fatigue and weakness. High-grade fever is also common but not specific to pulmonary tuberculosis. Weight loss, not weight gain, is a classic symptom due to decreased appetite. Dry cough is a common symptom, but not as specific as lethargy in pulmonary tuberculosis.