Nokea
The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
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A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
- A. Anorexia
- B. Weight gain
- C. Distended abdomen
- D. Dyspnea
Correct Answer: D
Rationale: Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion from blood backing up into the lungs.
A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneously every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 167
Rationale: Calculation: 245 lbs ÷ 2.2 = 111.36 kg; 111.36 kg × 1.5 mg/kg = 167 mg
A nurse is reviewing the arterial blood gas (ABG) values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- C. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
- D. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
Correct Answer: A
Rationale: The values indicate metabolic acidosis with compensatory respiratory alkalosis, typical in CKD due to impaired acid excretion.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Determine if pain radiates to the left arm
- C. Check the client's blood pressure
- D. Auscultate heart tones
Correct Answer: A
Rationale: ECG is the primary diagnostic tool for MI, showing characteristic ST changes.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.