Nokea
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to swelling of neck
- B. Anxiety-related changes in body image
- C. Altered nutrition, less than body requirements, related to difficulty in swallowing
- D. Risk for ineffective airway clearance related to pressure on the trachea
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
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The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?
- A. 50 mL/hr
- B. 62 mL/hr
- C. 125 mL/hr
- D. 137 mL/hr
Correct Answer: C
Rationale: To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
The client is taking prednisone 7.5 mg po each morning to treat his systemic lupus erythematosis. Which statement best explains the reason for taking the prednisone in the morning?
- A. There is less chance of forgetting the medication if taken in the morning.
- B. There will be less fluid retention if taken in the morning.
- C. Prednisone is absorbed best with the breakfast meal.
- D. Morning administration mimics the body's natural secretion of corticosteroid.
Correct Answer: D
Rationale: Morning dosing aligns with the body's natural cortisol peak, minimizing adrenal suppression.