Nokea
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
- A. Pallor
- B. Hypertension
- C. A low hematocrit level
- D. Pale mucous membranes
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
You may also like to solve these questions
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
- A. Administer oxygen via mask.
- B. Swaddle the neonate in heated blankets.
- C. Reassess the oximetry reading in 30 minutes.
- D. Draw blood gases for oxygen and carbon dioxide levels.
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
- A. Impotence
- B. Mood swings
- C. Increased appetite
- D. Complete atrioventricular (AV) block
Correct Answer: A
Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
- A. Assessment data, biochemical data, clinical data and dietary data
- B. Ancestral cultural data, biochemical data, clinical data and dietary data
- C. Anthropometric data, biological data, chemical data and dietary data
- D. Anthropometric data, biochemical data, clinical data and dietary data
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
- A. Is older than 65 years.
- B. Has had symptoms of the stroke less than 3 years.
- C. Has a blood pressure within normal limits.
- D. Does not have active internal bleeding.
- E. Has not had an alcoholic beverage within the last 8 hours.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.