Nokea
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.
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The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.
A client is scheduled for a myelogram at the outpatient clinic.
Which of the following statements, if made by the nurse, correctly describes a myelogram?
- A. The Test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown.'
- B. The Test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk.'
- C. The Test involves a lumbar puncture with injection of contrast medium, allowing accettare visualization of the vertebral canal.'
- D. The Test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a myelogram. (1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct-contrast medium or air is injected into spinal subarachnoid space through a spinal puncture, identifies tumors, cysts, herniated vertebral discs (4) no such procedure
A diagnosis of pernicious anemia is made by:
- A. Bone marrow aspiration
- B. Quantitative assay
- C. Weber test
- D. Schilling test
Correct Answer: D
Rationale: The Schilling test diagnoses pernicious anemia by assessing vitamin B12 absorption. Bone marrow aspiration, quantitative assays, or the Weber test (hearing) are not specific to this condition.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.