Nokea
The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations?
- A. Completing the spring semester of school.
- B. Gaining 4 pounds.
- C. Becoming engaged.
- D. Undergoing a root canal.
Correct Answer: D
Rationale: Stressful situations like surgery or dental procedures (e.g., root canal) increase glucocorticoid needs in Addison's disease to prevent adrenal crisis.
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Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
- A. Administer oxygen.
- B. Elevate the head of the bed 30 degrees.
- C. Administer a bolus of I.V. fluids.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following?
- A. The client asks what time the doctor will visit that day.
- B. The client asks about the supplies used during the dressing change.
- C. The client talks about something she read in the morning newspaper.
- D. The client complains about the way the night nurse changed the dressing.
Correct Answer: B
Rationale: The client's inquiry about the supplies used during the dressing change indicates interest and readiness to participate in her colostomy care. Other options reflect unrelated concerns or dissatisfaction, not readiness to engage in self-care. CN: Psychosocial adaptation; CL: Evaluate
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 1 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.
- A. blood pressure
- B. temperature
- C. pulse and respirations
- D. pulse oximetry
- E. lung sounds
- F. neurological assessment findings
- G. thready peripheral pulses
Correct Answer: A,B,C,F,G
Rationale: Blood pressure (94/57) indicates hypotension, temperature (105°F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion—all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.