Nokea
The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.
- A. Dysuria
- B. Jaundice
- C. Low back pain
- D. Night sweats
- E. Weight loss
- F. Purulent or blood-tinged sputum
Correct Answer: D,E,F
Rationale: Night sweats, weight loss, and purulent/blood-tinged sputum are hallmark symptoms of pulmonary tuberculosis.
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A client is on a low-residue diet. All of the following are on the client's tray. Which should be removed?
- A. Roast beef
- B. Mashed potato
- C. Strawberry jam
- D. White bread
Correct Answer: C
Rationale: Strawberry jam contains seeds, which increase intestinal residue, contraindicated in a low-residue diet. Roast beef, mashed potatoes, and white bread are low-fiber and appropriate.
An 8-year-old child is admitted to the hospital with pneumonia. The child has had frequent respiratory infections. A chloride sweat test is ordered. The nurse knows that the reason for this test is to rule out which condition?
- A. Pernicious anemia
- B. Diabetes insipidus
- C. Cystic fibrosis
- D. Glomerulonephritis
Correct Answer: C
Rationale: Frequent respiratory infections and pneumonia suggest cystic fibrosis, diagnosed via chloride sweat test, which detects elevated sweat chloride levels.
The nurse is caring for a client who has been in alcohol detoxification for one week. The client has slurred speech and is bumping into doorframes and walking unsteadily. What is the most appropriate initial action by the nurse?
- A. Assess for Wernicke-Korsakoff syndrome
- B. Ask for an order for blood alcohol level
- C. Request a neurology consult
- D. Administer a PRN dose of diazepam (Valium)
Correct Answer: A
Rationale: Slurred speech and unsteady gait post-detox may indicate Wernicke-Korsakoff syndrome, a thiamine deficiency complication, requiring urgent assessment.
The best choice for the child following a tonsillectomy is:
- A. Fruit punch
- B. Grape soda
- C. A banana Popsicle
- D. Ice cream
Correct Answer: C
Rationale: A banana Popsicle is soothing, cold, and non-irritating to the surgical site. Liquids like punch or soda may sting, and ice cream is dairy, which can increase mucus.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.