Nokea
The client with a suspected pituitary tumor will most likely exhibit symptoms of:
- A. Alteration in visual acuity
- B. Frequent diarrhea
- C. Alterations in blood glucose
- D. Urticaria
Correct Answer: A
Rationale: Pituitary tumors can compress the optic chiasm, leading to visual disturbances. Diarrhea , blood glucose changes , and urticaria are less commonly associated with pituitary tumors.
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A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned children.'
- B. Port wine stains are often associated with other malformations.'
- C. Telangiectatic nevi are normal and will disappear as the baby grows.'
- D. The child is too young for consideration of surgical removal of these at this time.'
Correct Answer: C
Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.
A client receiving HTZ (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
- A. A pear
- B. An apple
- C. An orange
- D. A banana
Correct Answer: D
Rationale: Hydrochlorothiazide is a diuretic that can cause potassium loss. Bananas are high in potassium, making them the best choice. Pears , apples , and oranges have less potassium.
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.