Nokea
The nurse is assessing for abdominal pulsations in a client with a visible mass below the umbilicus. The nurse should use which technique?
- A. light palpation
- B. inspection
- C. percussion
- D. deep palpation
Correct Answer: B
Rationale: Inspection is used to visually assess for abdominal pulsations or masses. Palpation or percussion may be used later but are not the initial technique for observing pulsations.
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The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:
- A. Increased weight
- B. A sore throat
- C. Difficulty in sleeping
- D. Changes in mood
Correct Answer: B
Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.
Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:
- A. Uterine atony
- B. Retained placental fragments
- C. Cervical laceration
- D. Perineal tears
Correct Answer: B
Rationale: Retained placental fragments are the most common cause of late postpartum hemorrhage, as they prevent proper uterine contraction and hemostasis.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
- A. Tell the client to avoid a tub bath for 48 hours
- B. Tell the client to expect clay-colored stools
- C. Tell the client that she can expect lower abdominal pain for the next week
- D. Tell the client to report pain in the back or shoulders
Correct Answer: D
Rationale: Pain in the back or shoulders post-laparoscopic cholecystectomy may indicate referred pain from residual CO2 or complications, requiring prompt reporting.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.