Nokea
The nurse is assisting with community health screening. Which of the following clients is the priority to refer for further evaluation?
- A. client with a random blood glucose of 139 mg/dL (7.1 mmol/L)
- B. client with shiny, hairless legs that are cool to the touch
- C. client who is an athlete with a heart rate of 50/min
- D. client with a blood pressure of 129/79 mm Hg
Correct Answer: B
Rationale: Shiny, hairless legs that are cool to the touch suggest peripheral artery disease, a serious condition requiring urgent evaluation. A is within normal glucose range (71-200 mg/dL). C is normal for an athlete. D indicates prehypertension, which is less urgent than vascular disease.
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The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider?
- A. Client with bronchospasm who is due to receive nebulized acetylcysteine
- B. Client with chronic obstructive pulmonary disease due to receive PO prednisone
- C. Client with cystic fibrosis who is due to receive PO pancreas with breakfast
- D. Client with suspected bacterial pneumonia due to receive IV levofloxacin
Correct Answer: A
Rationale: Acetylcysteine is used for mucus thinning, not bronchospasm, which requires bronchodilators. The other medications are appropriate for their respective conditions.
A thyroid scan, a cardiac catheterization, a gallbladder x-ray, and an intravenous pyelogram are ordered for a client. Which test should the nurse schedule to be done first?
- A. Thyroid scan
- B. Cardiac catheterization
- C. Gallbladder x-ray
- D. Intravenous pyelogram
Correct Answer: A
Rationale: Thyroid scans use radioactive iodine, which can interfere with other tests' contrast agents or imaging. Scheduling it first prevents interaction with cardiac catheterization, gallbladder x-ray, or IVP.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
- A. High calorie, low fat, low sodium
- B. High protein, low fat, low carbohydrate
- C. High protein, high calorie, unrestricted fat
- D. High carbohydrate, low protein, moderate fat
Correct Answer: C
Rationale: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?
- A. Permission to videotape
- B. Salivary pH
- C. Mini-mental status exam
- D. Pre-anesthesia work-up
Correct Answer: D
Rationale: Pre-anesthesia work-up. ECT is delivered under general anesthesia and the client should be prepared as for any procedure involving anesthesia.
The nurse is auscultating an elderly bedridden client's breath sounds and hears crackles. What is the best interpretation of this finding?
- A. This is normal for the client's age.
- B. This is suggestive of an immediately life-threatening condition.
- C. This is an indication that the client needs to take deep breaths.
- D. This is an indication that the client may need nasal oxygen.
Correct Answer: C
Rationale: Crackles in a bedridden elderly client suggest fluid in the lungs or atelectasis, which deep breathing can help clear. It's not normal, not immediately life-threatening, and oxygen is premature without further assessment.