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The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.
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What is the nurse's best action for a client with a C6 spinal cord injury?
- A. Assess respiratory status.
- B. Check bladder function.
- C. Monitor skin integrity.
- D. Evaluate motor strength.
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.
The nurse is preparing a client for a paracentesis. The nurse should:
- A. Have the client void immediately before the procedure.
- B. Place the client in a side-lying position.
- C. Initiate an I.V. line to administer sedatives.
- D. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
Correct Answer: A
Rationale: Voiding before paracentesis (A) prevents bladder injury. Side-lying (B) is incorrect; upright is preferred. IV sedatives (C) are not routine, and NPO (D) is unnecessary.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
- A. High oxygen concentrations will cause coughing and dyspnea.
- B. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
- C. Increased oxygen use will cause the client to become dependent on the oxygen.
- D. Administration of oxygen is contraindicated in clients who are using bronchodilators.
Correct Answer: B
Rationale: In COPD, high oxygen concentrations may suppress the hypoxic drive to breathe, risking CO2 retention. Oxygen does not cause coughing, dependency, or contraindication with bronchodilators.
The following scenario applies to the next 1 items
The emergency department nurse cares for a child with otitis media
Item 1 of 1
Nurses' Note
Vital Signs
Orders
1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
- A. ventrogluteal
- B. dorsogluteal
- C. Abdomen
- D. nerve damage.
- E. staining of the skin
- F. hydrocortisone
- G. EMLA (lidocaine and prilocaine)
Correct Answer: A,D,G
Rationale: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs?
- A. Egg yolks.
- B. Brown rice.
- C. Vegetables.
- D. Tea.
Correct Answer: A
Rationale: Microcytic anemia is often due to iron deficiency. Egg yolks are a good source of iron, particularly heme iron, which is highly bioavailable. Brown rice and vegetables contain non-heme iron but in lower amounts, and tea inhibits iron absorption due to tannins. Egg yolks are the best choice.