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The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct Answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.
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Which type of anemia is associated with chronic kidney disease?
- A. Iron-deficiency anemia
- B. Vitamin B12 deficiency anemia
- C. Aplastic anemia
- D. Erythropoietin deficiency anemia
Correct Answer: D
Rationale: The correct answer is D: Erythropoietin deficiency anemia. Chronic kidney disease often leads to anemia due to decreased production of erythropoietin. This hormone, produced by the kidneys, stimulates red blood cell production in the bone marrow. Iron-deficiency anemia (choice A) is more commonly caused by insufficient dietary iron intake or chronic blood loss. Vitamin B12 deficiency anemia (choice B) is usually due to inadequate dietary intake, malabsorption, or pernicious anemia. Aplastic anemia (choice C) is a bone marrow failure disorder characterized by pancytopenia (decreased red blood cells, white blood cells, and platelets) rather than a deficiency in erythropoietin production.
A client who _____ diet requires _____ amounts of vitamin C.
- A. Follows a vegan diet
- B. Smokes cigarettes
- C. Follows a vegetarian diet
- D. Follows a ketogenic diet
Correct Answer: B
Rationale: Clients who smoke require more vitamin C due to increased oxidative stress and depletion of vitamin C. Smoking leads to the generation of free radicals in the body, causing oxidative stress and consuming higher levels of antioxidants like vitamin C. Choices A, C, and D are incorrect as they do not directly relate to the increased need for vitamin C as seen in smokers.
Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: B
Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).
Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'listening and responding to soldiers' suggestions and complaints'?
- A. Accountability
- B. Personal/professional development
- C. Individual training
- D. Military appearance/physical condition
Correct Answer: A
Rationale: The correct answer is A. Accountability in personnel management involves being answerable for one's actions and decisions, which includes listening to and addressing the suggestions and complaints of soldiers. This category focuses on the responsibility and answerability aspect of the nurse manager's role. Choices B, C, and D are incorrect because personal/professional development is about growth and improvement, individual training pertains to specific skill development, and military appearance/physical condition relates to the physical presentation and fitness levels, none of which directly address the task of listening and responding to soldiers' suggestions and complaints.
The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip before initiating the Coumadin
- B. Check the client's INR before beginning Coumadin
- C. Clarify the order with the healthcare provider as soon as possible
- D. Administer the Coumadin along with the heparin drip as ordered
Correct Answer: D
Rationale: The correct answer is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip before initiating Coumadin can increase the risk of clot formation. Checking the client's INR before starting Coumadin is important but not the immediate action required. Clarifying the order with the healthcare provider is not necessary as both medications are commonly used together.