Nokea
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous.
- B. The stoma is dark red to purple.
- C. The stoma oozes a small amount of blood.
- D. The stoma does not expel stool.
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
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Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.
The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods?
- A. Proper body alignment.
- B. Elevating the part.
- C. Prone lying positions.
- D. Positions of flexion.
Correct Answer: D
Rationale: Positions of flexion can exacerbate joint stiffness and deformity in rheumatoid arthritis. Proper alignment, elevation, and prone positions (if comfortable) support joint health.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.
Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested?
- A. Ketoconazole suppresses adrenal steroid secretion.
- B. Ketoconazole destroys adrenocortical cells, resulting in a 'medical' adrenalectomy.
- C. Ketoconazole increases adrenocorticotropic hormone (ACTH)-induced corticosteroid serum levels.
- D. Ketoconazole decreases duration of adrenal suppression when administered with corticosteroids.
Correct Answer: A
Rationale: Ketoconazole inhibits adrenal steroid synthesis, reducing cortisol production, which can be therapeutic in Cushing's disease.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.