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The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.
- A. Coarse crackles
- B. Dyspnea
- C. Pallor
- D. Respiratory depression
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (B), pallor (C), and tachycardia (E) as compensatory mechanisms. Crackles (A) suggest fluid overload, and respiratory depression (D) is unrelated.
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A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
- A. Blood pressure 94/60
- B. Heart rate 76 BPM
- C. Urine output 50 ml/hour
- D. Respiratory rate 16
Correct Answer: A
Rationale: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment?
- A. 20-year-old college student who reports a ringlike, red bull’s-eye-shaped, itchy leg rash after hiking in the woods 2 days ago
- B. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching
- C. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
- D. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
Correct Answer: C
Rationale: Headaches and gait disturbance in a 78-year-old on warfarin post-fall (C) suggest a possible subdural hematoma, a life-threatening condition requiring immediate evaluation. Bull’s-eye rash (A) suggests Lyme disease, vaginal discharge (B) indicates yeast infection, and diarrhea (D) is a colchicine side effect, all less urgent.
The nurse caring for a client with anemia recognizes which clinical manifestation as one specific for a hemolytic type of anemia?
- A. Jaundice
- B. Anorexia
- C. Tachycardia
- D. Fatigue
Correct Answer: A
Rationale: The destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with anemia but are not specific to hemolytic. Answer B does not relate.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.