Nokea
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site.
- B. Irrigate with 5 mls of 0.9% Normal Saline.
- C. Palpate for a thrill over the fistula.
- D. Check color and warmth in the extremity.
Correct Answer: C
Rationale: A thrill confirms blood flow through the fistula.
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What is the nurse’s evaluation of Mr. Singer not testing for proper placement of his nasogastric tube?
- A. Mr. Singer must be stopped before the instillation of the feeding
- B. There is no possibility that the tube will get into Mr. Singer’s trachea
- C. If Mr. Singer shows no breathing difficulties, he can proceed with his feeding
- D. The greatest danger for Mr. Singer is the aspiration of the feeding into his lung
Correct Answer: D
Rationale: Aspiration poses a serious risk if the tube is misplaced.
Symptoms indicative of cervical cancer include:
- A. Irregular vaginal bleeding
- B. Bloating
- C. Weight gain and nausea
- D. Dyspareunia
Correct Answer: A
Rationale: Irregular vaginal bleeding is a hallmark symptom of cervical cancer, often occurring between periods or after intercourse.
You are taking histories from several clients who report vertigo. Which client report concerns you the most?
- A. Vertigo with hearing loss
- B. Episodic vertigo
- C. Vertigo without hearing loss
- D. Merry-go-round' vertigo
Correct Answer: A
Rationale: Vertigo accompanied by hearing loss may indicate Meniere's disease or other serious inner ear disorders requiring prompt evaluation.
The third stage of labor is when:
- A. Contractions reach their peak
- B. The head is visible
- C. The water breaks
- D. The placenta is delivered
Correct Answer: D
Rationale: The third stage of labor involves the delivery of the placenta after the baby is born.
7. According to Traditional Chinese Medicine, when does disease occur?
- A. Yin and yang become imbalanced, altering the flow of Qi.
- B. Acupoints in Qi channels become obstructed, preventing the release of Qi.
- C. The body’s natural healing abilities are impaired by obstruction of fluid channels.
- D. The individual is out of harmony with nature and requires spiritualism and mysticism to reestablish balance.
Correct Answer: A
Rationale: In Traditional Chinese Medicine, disease occurs when Yin and Yang become imbalanced, disrupting the flow of Qi, as described in option A.