Nokea
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
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A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
- A. Reduce the client's anxiety.
- B. Maintain adequate oxygenation.
- C. Decrease chest pain.
- D. Maintain adequate circulating volume.
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace?
- A. Have the client in a side-lying position.
- B. Verify the order for the settings for the brace.
- C. Ask the client to stand with arms held away from the body.
- D. Assist the client to log roll and rise to a sitting position.
Correct Answer: B,A,D,C
Rationale: Verifying the order ensures correct settings, side-lying positions the client safely, log rolling prevents twisting, and standing allows proper brace fitting.
A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
- A. Potentiating the action of insulin.
- B. Lowering the renal threshold of glucose.
- C. Stimulating insulin release from functioning beta cells in the pancreas.
- D. Combining with glucose to render it inert.
Correct Answer: C
Rationale: Tolbutamide, a sulfonylurea, stimulates insulin release from pancreatic beta cells, helping to lower blood glucose levels in type 2 diabetes.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.