Nokea
Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?
- A. Dyspnea and reduced or absent breath sounds over the right lung
- B. Tachycardia, hypotension, and cool, clammy skin
- C. Fever, rebound tenderness, and abdominal rigidity
- D. Redness, warmth, and drainage at the biopsy site
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient with Crohn's disease is admitted after 4 days of diarrhea. Which of the following urine specific gravity values do you expect to find in this patient?
- A. 1.005
- B. 1.011
- C. 1.02
- D. 1.03
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?
- A. There is no skin breakdown.
- B. Her appetite improves.
- C. She loses more than 10 lbs.
- D. Stools are less fatty and decreased in frequency.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct Answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct Answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?
- A. Administering a lactulose enema as ordered.
- B. Encouraging a protein-rich diet.
- C. Administering sedatives, as necessary.
- D. Encouraging ambulation at least four times a day.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.