Nokea
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
- A. Assessment of the client's level of anxiety
- B. Evaluation of the client's exercise tolerance
- C. Identification of peripheral pulses
- D. Assessment of bowel sounds and activity
Correct Answer: C
Rationale: The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.
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When discussing the patterns of use of alcohol and other drugs, which piece of information should the nurse include?
- A. Lifetime prevalence and intensity of alcohol use are greater in men than in women.
- B. Caucasians report higher levels of alcohol use than African Americans or Hispanics.
- C. Overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age.
- D. Heavy use is more common in lower socioeconomic groups due to affordability.
Correct Answer: C
Rationale: The correct answer is that overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age. Recent research indicates that alcohol and illicit drug use tends to rise into the mid-20s and then decline with age. Choices A and B are incorrect because lifetime prevalence and intensity of alcohol use are greater in men than in women, and Caucasians do not report higher levels of alcohol use compared to African Americans or Hispanics. Choice D is incorrect because heavy use is more common in lower socioeconomic groups due to factors like stress, coping mechanisms, and availability, not just affordability.
The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?
- A. "I live by myself."?
- B. "I have trouble seeing."?
- C. "I have a cat in the house with me."?
- D. "I usually drive myself to the doctor."?
Correct Answer: B
Rationale: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and are incorrect. Living alone (Choice A) does not necessarily indicate a need for follow-up unless there are specific concerns. Having a cat at home (Choice C) and driving to the doctor (Choice D) are not direct indicators of the client's ability to care for himself.
The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:
- A. 900
- B. 1200
- C. 1700
- D. 2100
Correct Answer: C
Rationale: Sodium warfarin is typically administered in the late afternoon, around 1700 hours. This timing allows for accurate bleeding times to be drawn in the morning. Administering it at 0900 (choice A) would not align with this schedule and may affect the monitoring of bleeding times. Choice B (1200) is midday, which is not the recommended time for sodium warfarin administration. Choice D (2100) is in the evening, which is also not ideal. Therefore, the correct time for administering sodium warfarin is 1700 (choice C).
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
- A. Taking the vital signs of the 5-month-old with bronchiolitis
- B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
- C. Administering medication to the 2-year-old with periorbital cellulitis
- D. Adjusting the traction of the 1-year-old with a fractured tibia
Correct Answer: B
Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.
Which laboratory test would be the least effective in diagnosing a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.