Nokea
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
- A. Monitoring for bleeding
- B. Administering diuretics
- C. Monitoring blood glucose
- D. Assessing for infection
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.
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The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication?
- A. I will take the medication each morning after breakfast.
- B. I will check my heart rate before taking the medication.
- C. I will report visual disturbances to my doctor.
- D. I will stop the medication if I develop gastric upset.
Correct Answer: C
Rationale: Reporting visual disturbances is important, as levothyroxine can rarely cause visual changes, indicating a need for medical evaluation. It should be taken before breakfast, not stopped for gastric upset.
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
- A. Assess the client's respirations
- B. Notify the physician
- C. Auscultate fetal heart rate
- D. Transfer to delivery suite
Correct Answer: C
Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.
The nurse is performing an assessment on a client with a history of a tension pneumothorax. Which finding is most concerning?
- A. Tracheal deviation
- B. Chest pain
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Tracheal deviation in a tension pneumothorax indicates mediastinal shift from increased intrathoracic pressure, a life-threatening emergency requiring immediate attention.
Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
- A. Hyperammonemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.