Nokea
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.
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The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?
- A. playing alone, with no interaction with other children
- B. playing cooperatively in a single-sex group
- C. playing parallel to other children, but not playing together
- D. playing and interacting cooperatively in a mixed-sex group
Correct Answer: C
Rationale: Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.
The nurse is reviewing medications with a client who is to be scheduled for outpatient rotator cuff repair. Which of the following medications does the nurse anticipate the client will be advised to avoid on the morning of the surgery?
- A. Metoprolol.
- B. Synthroid.
- C. Aspirin.
- D. Prozac.
Correct Answer: C
Rationale: Aspirin (C) is typically avoided before surgery due to its antiplatelet effects, which increase bleeding risk. Metoprolol (A), Synthroid (B), and Prozac (D) are generally continued unless otherwise directed.
Which of the following signs and symptoms would a nurse expect when examining a 22-year-old female with secondary syphilis?
- A. chancre sore near the vagina
- B. no noticeable symptoms
- C. non-itchy rash on palms and soles of the feet
- D. skin tumors
Correct Answer: C
Rationale: Secondary syphilis presents with a non-itchy rash, often on the palms and soles. Chancres are primary syphilis, and skin tumors are tertiary syphilis.
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.