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The nurse has just received report on 4 clients. Which of the following reported information is the most concerning?
- A. Client on a heparin drip with an activated PTT of 60 seconds
- B. Client reporting back pain 1 hour following coronary angiography
- C. Client with a head injury and a Glasgow Coma Scale score of 14
- D. Client with incisional pain rated as 6 on a scale of 0-10, two days after coronary artery bypass graft
Correct Answer: B
Rationale: Back pain shortly after coronary angiography may indicate retroperitoneal bleeding, a life-threatening complication requiring immediate investigation. The other conditions are less acute or expected.
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A client is seen in the clinic and determined to have a hydatidiform mole. Which diagnostic test can confirm the diagnosis of a hydatidiform mole?
- A. An ultrasound
- B. Alpha-fetoprotein
- C. Human chorionic gonadotrophin
- D. Lecithin sphingomyelin ratio
Correct Answer: A
Rationale: Ultrasound is the primary diagnostic tool for confirming a hydatidiform mole, showing a characteristic 'snowstorm' pattern. Elevated human chorionic gonadotropin supports the diagnosis but is not confirmatory alone.
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply.
- A. Atorvastatin
- B. Metformin
- C. Metoprolol
- D. Olanzapine
- E. Omeprazole
Correct Answer: C,D
Rationale: Metoprolol, a beta-blocker, can cause orthostatic hypotension, leading to dizziness on standing. Olanzapine, an antipsychotic, is associated with orthostatic hypotension as a side effect. A, B, and E are not commonly linked to orthostatic symptoms; atorvastatin manages cholesterol, metformin controls blood sugar, and omeprazole reduces stomach acid.
A thyroid scan, a cardiac catheterization, a gallbladder x-ray, and an intravenous pyelogram are ordered for a client. Which test should the nurse schedule to be done first?
- A. Thyroid scan
- B. Cardiac catheterization
- C. Gallbladder x-ray
- D. Intravenous pyelogram
Correct Answer: A
Rationale: Thyroid scans use radioactive iodine, which can interfere with other tests' contrast agents or imaging. Scheduling it first prevents interaction with cardiac catheterization, gallbladder x-ray, or IVP.
A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?
- A. 25-year-old client who reports a fish-like vaginal odor for the past month
- B. 30-year-old client with an intrauterine device who reports heavy bleeding with menses
- C. 40-year-old client with endometriosis who reports persistent pain during intercourse
- D. 60-year-old client who reports bloating and pelvic pressure for the past 2 months
Correct Answer: D
Rationale: Bloating and pelvic pressure in a 60-year-old client may indicate serious conditions such as ovarian cancer or other pelvic masses, which require urgent evaluation. Fish-like odor suggests bacterial vaginosis, heavy bleeding with an IUD is common, and pain with endometriosis is expected, making these less concerning.
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.