Nokea
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.
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The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:
- A. Infection with the tubercle bacillus
- B. Exposure to the tubercle bacillus
- C. Questionable exposure to the tubercle bacillus
- D. No exposure to the tubercle bacillus
Correct Answer: B
Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.
An adult who had a cerebrovascular accident (CVA) with expressive aphasia has started saying some words. The client's family is quite upset because the words are mostly profanity. They tell the nurse that the client usually does not use profanity. How should the nurse respond to the family?
- A. She must be in a lot of pain to use profanity. We will assess her for pain.'
- B. Many people who have had aphasia following a stroke use profanity when speech first returns. Other words will soon follow.'
- C. It is not appropriate for her to use profanity when speaking to the nurses. We will discipline her when this happens.'
- D. She must be upset with you or us. We will try to find out what is bothering her.'
Correct Answer: B
Rationale: Profanity in early expressive aphasia post-CVA is common due to disinhibition in damaged brain areas; reassuring the family that other words will follow is appropriate.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.