Nokea
The nurse is caring for a client with a history of Barrett’s esophagus. The nurse should expect the client to have:
- A. Chronic acid reflux
- B. Epigastric pain
- C. Hematemesis
- D. Dysphagia
Correct Answer: A
Rationale: Barrett’s esophagus results from chronic acid reflux, causing esophageal lining changes, a key risk factor for esophageal cancer.
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The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. Blowing air under the cast using a hair dryer on cool setting often relieves itching.
- B. Slide a ruler under the cast and scratch the area.
- C. Guide a towel under and through the cast and move it back and forth to relieve the itch.
- D. Gently thump on cast to dislodge dried skin that causes the itching.
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Platelet count
- B. Prothrombin time (PT/INR)
- C. Hemoglobin
- D. Serum potassium
Correct Answer: B
Rationale: Warfarin affects clotting, requiring monitoring of PT/INR to ensure therapeutic anticoagulation. Platelets (A), hemoglobin (C), and potassium (D) are not directly affected.
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. A left hemothorax
- B. A right hemothorax
- C. Intubation of the right mainstem bronchus
- D. An inadequate mechanical ventilator
Correct Answer: C
Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.
The nurse is caring for a client with a history of psoriasis. The nurse should expect the client to have:
- A. Scaly plaques
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Psoriasis causes scaly, silvery plaques due to rapid skin cell turnover, a hallmark symptom.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.