Nokea
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
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Because the client has hypothyroidism, the nurse expects which of the following to be present in the client?
- A. Weight loss
- B. Respiratory rate of 30/minute
- C. Temperature of 96.8°F
- D. Scanty menses
Correct Answer: C
Rationale: Hypothyroidism slows metabolism, causing hypothermia (e.g., 96.8°F). Weight gain, not loss, slow respirations, and heavy menses are typical.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
The nurse is caring for a woman who has internal radiation for cancer of the cervix. Which of the following situations poses the greatest risk for others?
- A. The client's daughter spends several hours sitting next to the client's bed.
- B. The client's husband kisses her and visits for five minutes before leaving.
- C. The nurse brings the client her lunch tray and sets it up on the overbed table for her.
- D. The cleaning lady damp mops the room.
Correct Answer: A
Rationale: Prolonged close contact (daughter's hours-long visit) increases radiation exposure risk. Brief visits, tray setup, or mopping pose minimal risk.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
- A. Massage the abdomen gently.
- B. Reduce the amount of irrigation solution.
- C. Increase his oral intake.
- D. Place a heating pad on the abdomen.
Correct Answer: A
Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
The nurse is observing a nursing assistant move a client from bed to chair. Which action by the nursing assistant indicates a lack of understanding about transfer techniques?
- A. Bending from the waist when moving the person
- B. Keeping the feet separated when lifting and moving the person
- C. Turning the whole body when moving the person to the chair
- D. Asking for help in moving the person from bed to chair
Correct Answer: A
Rationale: Bending from the waist risks back injury, indicating improper technique. Wide stance, whole-body turning, and seeking help are correct.