Nokea
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
- A. Apply a tourniquet to the client's arm
- B. Administer an anticonvulsant medication
- C. Ask the client if he is allergic to shellfish
- D. Apply a blood pressure cuff to the arm
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb). Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
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The nurse is performing an assessment on a client with a history of pancreatitis. Which finding is most concerning?
- A. Abdominal tenderness
- B. Nausea and vomiting
- C. Fever of 101°F
- D. Grey-Turner’s sign
Correct Answer: D
Rationale: Grey-Turner’s sign (flank bruising) indicates retroperitoneal hemorrhage in pancreatitis, a life-threatening complication requiring immediate attention. Other findings are common but less severe.
The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?
- A. Administering pain medication
- B. Preventing infection
- C. Monitoring blood glucose levels
- D. Encouraging high-fiber foods
Correct Answer: B
Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
- A. Prepare an injection of vitamin K
- B. Irrigate the urinary catheter with 50 mL of normal saline
- C. Offer the client additional oral fluids
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
- A. Hypoxia, shortness of breath, and exertional fatigue
- B. Weight loss, increased RBC, and fever
- C. Rales, edema, and enlarged spleen
- D. Edema of the lower extremities and distended neck veins
Correct Answer: D
Rationale: Cor pulmonale, right heart failure from lung disease, causes lower extremity edema and distended neck veins due to increased venous pressure. Hypoxia and fatigue are general emphysema symptoms.
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.