Nokea
The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?
- A. Bilateral leg edema
- B. Warm, red, swollen calf
- C. Mild leg cramping
- D. Pale, cool foot
Correct Answer: B
Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (A) suggests heart failure, cramping (C) is nonspecific, and pale/cool foot (D) indicates arterial occlusion.
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Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
- A. Increased PaCO2
- B. Decreased PaO2
- C. Increased HCO3
- D. Decreased base excess
Correct Answer: C
Rationale: Increased PaCO2 is present in both acute and chronic respiratory acidosis due to hypoventilation. Decreased PaO2 may occur in respiratory acidosis but does not differentiate acute from chronic. Increased HCO3 indicates renal compensation, which occurs in chronic respiratory acidosis as the body attempts to buffer the excess CO2, but not in acute cases where compensation has not yet occurred. Decreased base excess is not specific to differentiating acute from chronic respiratory acidosis.
A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
- A. Processed cheese
- B. Cottage cheese
- C. Cream cheese
- D. Cheddar cheese
Correct Answer: D
Rationale: MAOIs like tranylcypromine interact with tyramine-rich foods like aged cheddar cheese, causing hypertensive crisis. Processed, cottage, and cream cheeses have lower tyramine content.
A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?
- A. Severe nausea and vomiting
- B. Uterine size smaller than expected
- C. Fetal heart tones at 12 weeks
- D. All of the above
Correct Answer: A
Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.