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The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?
- A. This is a normal finding indicating no problem in the sinuses.
- B. Inflammation is present in the sinuses.
- C. The cavity likely contains fluid or pus.
- D. The client has a sinus infection.
Correct Answer: C
Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.
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A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of 6 pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: A weight gain of 6 pounds in a week suggests fluid retention, indicating possible overdosage of glucocorticoids, requiring adjustment.
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
- A. Uncompensated respiratory acidosis
- B. Uncompensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
The nurse is preparing a client with type 2 diabetes for a CT with contrast to evaluate diverticulitis with a possible mass. Which of the following medications on the client's medication list would be of concern to the nurse?
- A. fish oil
- B. warfarin (Coumadin)
- C. fluoxetine (Prozac)
- D. metformin (Glucophage)
Correct Answer: D
Rationale: Metformin should be held before and after contrast CT due to the risk of lactic acidosis if renal function is impaired by contrast dye.
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- A. Administer oxygen via nasal cannula
- B. Have narcan (naloxane) available
- C. Prepare to administer blood products
- D. Prepare to do cardioresuscitation
Correct Answer: B
Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.