Nokea
The nurse is assessing a client with acute diverticulitis. Which symptom requires immediate reporting to the physician?
- A. Mild left lower quadrant pain.
- B. Temperature of 101°F (38.3°C).
- C. Soft, formed stools.
- D. Nausea without vomiting.
Correct Answer: B
Rationale: A temperature of 101°F (38.3°C) in acute diverticulitis may indicate worsening infection or abscess, requiring immediate reporting. Mild pain, formed stools, and nausea are less urgent unless escalating. CN: Physiological adaptation; CL: Analyze
You may also like to solve these questions
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack?
- A. Occupational exposure to toxins.
- B. Viral respiratory infections.
- C. Exposure to cigarette smoke.
- D. Exercising in cold temperatures.
Correct Answer: B
Rationale: Viral respiratory infections are a leading trigger of acute asthma attacks due to airway inflammation. Toxins, smoke, and cold exercise are also triggers but less common.
A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hour. Which of the following is the most likely cause?
- A. Bowel obstruction.
- B. Adverse effect of opioid analgesics.
- C. Hemorrhage.
- D. Hypertension.
Correct Answer: B
Rationale: Opioid analgesics, commonly used post-surgery, can cause urinary retention by relaxing the bladder, reducing urine output. This is the most likely cause in this scenario.
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.