Nokea
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
- A. Decreased cardiac output
- B. Tissue hypoxia
- C. Cerebral edema
- D. Reduced oxygen saturation
Correct Answer: B
Rationale: Tissue hypoxia. Iron deficiency anemia reduces oxygen-carrying capacity, causing tissue hypoxia.
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Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)
The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?
- A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
- B. Client is lying with knees drawn up to the abdomen to alleviate pain
- C. Temperature is 102.2°F (39°C) with increasing abdominal pain
- D. Five large, liquid stools are yellow and foul-smelling
Correct Answer: C
Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?
- A. Avoid strenuous activity before the surgery
- B. Continue to exercise, even if angina occurs. It will strengthen your heart muscles
- C. Take short walks 3 times a day
- D. There are no activity restrictions unless angina occurs
Correct Answer: A
Rationale: Strenuous activity risks syncope or ischemia in aortic stenosis, so avoidance is critical. Exercise despite angina is dangerous, short walks may still trigger symptoms, and no restrictions ignore risks.
Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?
- A. Keep the client NPO for eight hours
- B. Ask the client about claustrophobia
- C. Ask the client about allergies to shellfish
- D. Encourage fluids
Correct Answer: C
Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.
Magnetic resonance imaging has been ordered for a client. Which factor should the nurse report to the physician?
- A. The client states she had an allergic reaction to iodine.
- B. The client has a pacemaker.
- C. The client wears a hearing aid.
- D. The client takes digoxin.
Correct Answer: B
Rationale: A pacemaker is a contraindication for MRI due to magnetic interference, requiring immediate physician notification to ensure safety.