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The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
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. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Before undergoing a multigated acquisition scan, a client with suspected left sided heart failure should be medicated to relieve cough. Coughing can disrupt the accuracy of the scan results by affecting the heart's movement and leading to motion artifacts. Therefore, it is essential to address any coughing issues before the test to ensure reliable and accurate imaging of the heart's function. The other options, such as administering diuretics, avoiding fluid intake, and administering analgesics, are not directly related to optimizing the imaging quality of the multigated acquisition scan for a client with suspected left sided heart failure.
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.
How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The standard drip factor for an IV infusion set is typically 15 drops per milliliter. To calculate drops per minute, you would multiply the flow rate in milliliters per hour by the drip factor and divide by 60 minutes per hour.
recurrent urinary tract infection in children cause:
- A. arthritis
- B. recurrent rash
- C. growth disturbance
- D. behavioral disturbances
Correct Answer: C
Rationale: Recurrent urinary tract infections (UTIs) in children can potentially cause growth disturbance. UTIs in children can result in poor weight gain, failure to thrive, and reduced height due to the stress and inflammatory response on the body. Chronic inflammation from recurrent UTIs can affect a child's overall health and development, leading to growth disturbances. It is essential to promptly treat and prevent recurrent UTIs in children to avoid potential long-term complications such as growth disturbances. Arthritis, recurrent rash, and behavioral disturbances are not typically associated with recurrent UTIs in children.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.