Nokea
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication of IV fluids, potentially leading to heart failure. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.
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A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
- A. Isograft
- B. Autograft
- C. Homograft
- D. Xenograft
Correct Answer: D
Rationale: A Jewish client may find a xenograft unacceptable due to religious dietary laws that prohibit the use of certain animal products, such as porcine grafts. An isograft (from an identical twin), autograft (from the client's own body), and homograft (from a human donor) are generally more acceptable. Answers A, B, and C are incorrect because they do not typically conflict with Jewish religious beliefs.
The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.
A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include
- A. heart palpitations.
- B. dizziness when walking.
- C. blurred vision.
- D. digital sensitivity to cold.
Correct Answer: D
Rationale: vasculitis of blood vessels in upper and lower extremities
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following instructions should the nurse include?
- A. Take the medication with milk.
- B. Remain upright for 30 minutes after taking.
- C. Stop the medication if bone density improves.
- D. Avoid regular bone density Test s.
Correct Answer: B
Rationale: Remaining upright for 30 minutes prevents esophageal irritation from alendronate. Options A, C, and D are incorrect.
The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?
- A. Leave the room
- B. Open the curtains
- C. Say, 'You sound upset.'
- D. Say, 'Women are more than breasts.'
Correct Answer: C
Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.