Nokea
The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?
- A. Hematuria
- B. Muscle spasms
- C. Dizziness
- D. Nausea
Correct Answer: A
Rationale: Hematuria in a client with pelvic and femur fractures suggests possible urinary tract or bladder injury, requiring immediate reporting.
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A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
- A. The client will experience confusion for a short time.
- B. Headache and muscle soreness are common.
- C. Some degree of memory loss, usually transient, may occur.
- D. Possible urinary incontinence may occur for 12 hours.
- E. The client may experience hallucinations for 2 to 3 weeks.
Correct Answer: A,B,C
Rationale: ECT causes short-term confusion (A), headache/muscle soreness (B), and transient memory loss (C). Incontinence (D) and prolonged hallucinations (E) are not typical.
A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?
- A. Clients have the right to view their medical records but may not copy any of the information contained in the records.
- B. Clients may be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance.
- C. Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan.
- D. It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information.
Correct Answer: C
Rationale: The Patient’s Bill of Rights includes the right to a fair review of claims against healthcare providers. Other options are incorrect or misrepresent client rights.
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- A. Cheyne-Stokes respirations
- B. Kussmaul respirations
- C. Biot respirations
- D. Diaphragmatic respirations
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.
The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.
- A. decreased ALT levels
- B. increased AST levels
- C. elevated ammonia levels
- D. low serum albumin levels
- E. shortened prothrombin time
Correct Answer: B, C, D
Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.
A client who has been diagnosed with lung cancer is starting a smoking-cessation program. Which of the following drugs would the nurse expect to be included in the program's plan?
- A. Bupropion SR (Zyban)
- B. Metoproterenol (Alupent)
- C. Oxitropium (Oxivent)
- D. Alprazolam (Xanax)
Correct Answer: A
Rationale: Bupropion SR (Zyban) is commonly used in smoking cessation programs to reduce nicotine cravings and withdrawal symptoms.