Nokea
The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects:
- A. Left atrial enlargement.
- B. Left ventricular enlargement.
- C. Right atrial enlargement.
- D. Right ventricular enlargement.
Correct Answer: B
Rationale: An apical impulse below the fifth intercostal space suggests left ventricular enlargement, common in heart failure due to ventricular dilation.
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A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has measured the correct dose when the syringe reads how many units?
Correct Answer: 32 units.
Rationale: The total dose is 10 units regular + 22 units NPH = 32 units, which should be drawn into one syringe for administration.
The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply.
- A. Fatigue.
- B. Unexplained weight loss with adequate nutritional intake.
- C. Rectal bleeding.
- D. Bowel changes.
- E. Positive fecal occult blood testing.
Correct Answer: A,B,C,D,E
Rationale: Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer, and blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic. CN: Health promotion and maintenance; CL: Create
Which of the following terms describes the condition of a client with the disease in dosage to maintain adequate analgesia?
- A. Pseudoaddiction.
- B. Physical dependence.
- C. Psychological dependence.
- D. Drug tolerance.
Correct Answer: D
Rationale: Drug tolerance occurs when a client requires increased doses to maintain analgesia due to the body's adaptation to the medication.
Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.
- A. Violent vomiting.
- B. Severe diarrhea.
- C. Abdominal pain.
- D. Sensory neuropathy.
- E. Persistent cough.
Correct Answer: A,B,C
Rationale: Arsenic poisoning typically presents with acute gastrointestinal symptoms such as violent vomiting, severe diarrhea, and abdominal pain due to its toxic effects on the digestive system. Sensory neuropathy and persistent cough are less common immediate symptoms.