Nokea
The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
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The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin inhibits platelet aggregation, reducing the risk of clot formation in transient ischemic attacks, which are precursors to stroke.
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
- A. You will be sitting for the examination procedure.
- B. Portions of the procedure will cause pain or discomfort.
- C. You will be asleep during the procedure.
- D. You will not be able to drink fluids for 24 hours following the study.
Correct Answer: B
Rationale: Renal biopsies may cause discomfort during needle insertion, and informing the client prepares them for the procedure.
Which symptom is not associated with glaucoma?
- A. Veil-like loss of vision
- B. Foggy loss of vision
- C. Seeing halos around lights
- D. Complaints of eye pain
Correct Answer: A
Rationale: Veil-like loss of vision is not typical of glaucoma; foggy vision, halos, and eye pain are common symptoms.