The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
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When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
The nurse is caring for a client with a history of Cushing’s syndrome.
- A. Which symptom is expected in a client with Cushing’s syndrome?
- B. Weight loss and fatigue.
- C. Moon face and truncal obesity.
- D. Hypotension and bradycardia.
- E. Polyuria and thirst.
Correct Answer: B
Rationale: Moon face and truncal obesity result from cortisol excess in Cushing’s syndrome. Weight loss, hypotension, and polyuria are more typical of Addison’s disease or diabetes insipidus.
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.2 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.0 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, and a potassium level of 3.2 mEq/L is low, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.0 mg/dL, and glucose 100 mg/dL do not require immediate action.
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