Nokea
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a leading cause of acute pancreatitis, so the physician's questions are relevant to determine etiology (A). Options B, C, and D are inaccurate or dismissive of the client's concerns.
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The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action?
- A. Document the prednisone with current medications.
- B. Notify the surgeon of the poison ivy.
- C. Notify the anesthesiologist of the prednisone administration.
- D. Send the client to surgery.
Correct Answer: C
Rationale: Prednisone use affects adrenal function and stress response, increasing risks during anesthesia. Notifying the anesthesiologist ensures proper perioperative management, such as stress-dose steroids.
Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk?
- A. Cool and damp weather.
- B. Active exercise and exertion.
- C. Physical and emotional stress.
- D. Rest and inactivity.
Correct Answer: C
Rationale: Physical and emotional stress can weaken the immune system, increasing the risk of tuberculosis recurrence. Weather, exercise, and rest do not directly influence recurrence.
The nurse should teach the client that signs of digoxin toxicity include which of the following?
- A. Rash over the chest and back.
- B. Increased appetite.
- C. Visual disturbances such as seeing yellow spots.
- D. Elevated blood pressure.
Correct Answer: C
Rationale: Visual disturbances, like seeing yellow spots (xanthopsia), are a hallmark of digoxin toxicity, requiring prompt reporting.
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
- A. Decreased pain
- B. Increased urinary output
- C. Decreased blood pressure
- D. Decreased temperature
- E. Increased muscle coordination
Correct Answer: A,D
Rationale: Ketorolac, an NSAID, reduces pain and inflammation, which can lower temperature in febrile clients. It does not directly affect urinary output, blood pressure, or muscle coordination.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.