Nokea
The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated
- B. The client on bed rest who ambulated to the bathroom
- C. The client with essential hypertension who has epistaxis and a headache
- D. The client with arterial occlusive disease who has a decreased pedal pulse
Correct Answer: C
Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.
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Whenever possible, patients evacuated from the theater of operations who are expected to return within 60 days are admitted to which of the following?
- A. Civilian hospitals participating in the National Disaster Medical System
- B. DOD tri-service hospitals
- C. Department of Veterans Affairs hospitals
- D. Field hospitals
Correct Answer: B
Rationale: Patients evacuated from the theater of operations who are expected to return within 60 days are admitted to DOD tri-service hospitals. These hospitals are equipped to provide specialized care tailored to military personnel. Choice A, civilian hospitals participating in the National Disaster Medical System, may not always have the necessary expertise and resources to cater specifically to military-related injuries. Choice C, Department of Veterans Affairs hospitals, primarily serve veterans and may not always accommodate short-term care for active-duty personnel. Choice D, field hospitals, are usually set up in temporary or emergency situations and are not designed for long-term care, making them less suitable for patients expected to return within 60 days.
A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?
- A. Eating meals
- B. Writing letters
- C. Combing the hair
- D. Dressing every morning
Correct Answer: B
Rationale: The correct answer is B: Writing letters. Writing requires fine motor skills, which are often impaired in a right-handed person with a right-sided CVA. Eating meals (choice A), combing the hair (choice C), and dressing every morning (choice D) involve gross motor skills and may not be as challenging for a right-handed individual with a right-sided CVA compared to the fine motor skill required for writing.
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
- B. Re-crossmatch the blood until the antibodies are identified
- C. Have the client sign a permit to receive uncrossmatched blood
- D. Have the unlicensed nursing assistant stay with the client
Correct Answer: A
Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.
During a physical assessment of a newborn, what finding should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A
Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.
Which of the following statements about medications is true?
- A. Over-the-counter medications are unlikely to interact with food or nutrients
- B. Prescription medications always have significant interactions with food
- C. Prescription and nonprescription drugs and herbal remedies interact with food
- D. Herbal products are generally safe since they are natural
Correct Answer: C
Rationale: The correct answer is C. This statement is true because both prescription medications and over-the-counter medications, along with herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is misleading because herbal products are not always safe, as they can have side effects and interact with other medications.