Nokea
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
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A patient with a history of myocardial infarction is prescribed aspirin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. Avoid taking this medication with other NSAIDs
- C. Discontinue the medication if you experience ringing in your ears.
- D. Take this medication only when you have chest pain.
Correct Answer: B
Rationale: Avoiding other NSAIDs prevents increased bleeding risk with aspirin, a key antiplatelet post-MI. Empty stomach increases GI upset, ringing requires reporting, and aspirin is daily, not PRN.
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy.
The nurse would suggest that the appropriate car seat for the child is
- A. the rear-facing seat.
- B. the front facing seat.
- C. the booster seat with car seat belt.
- D. the back seat.
Correct Answer: C
Rationale: A booster car seat is appropriate for a bigger child like a 4-year-old, ensuring proper restraint and safety.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
Francis is a 48-year-old female with elevated blood sugar level.
An immediate danger to confront Francis secondary to her elevated blood sugar level is
- A. albumin is negative.
- B. dehydration and impending shock.
- C. hyperglycemia.
- D. renal failure.
Correct Answer: B
Rationale: Glucose has an osmotic diuretic effect causing polyuria, which can lead to dehydration and impending shock if not addressed promptly.