Nokea
The nurse is part of an interdisciplinary team in a rehabilitation unit. Which of the following statements by a client is most important to be communicated to the social worker on the team?
- A. I can't afford to hire anyone to help me when I am discharged.
- B. I'm worried about falling when I go home.
- C. I need to learn how to get in and out of the shower.
- D. I'm not sure what kinds of adaptive equipment I will need.
Correct Answer: A
Rationale: Inability to afford help (A) is a social issue requiring the social worker's intervention for resources. Other concerns (B, C, D) are addressed by therapy or nursing.
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The nurse is caring for a client who is 14 weeks pregnant. The client is asking about vaccinations that can be given during pregnancy. Which of the following vaccines does the nurse tell the client that are safe during pregnancy?
- A. mumps
- B. measles
- C. smallpox
- D. influenza
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy. Mumps, measles, and smallpox vaccines are contraindicated.
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
- A. Closed chest drainage
- B. A tracheostomy
- C. A Swan Ganz Monitor
- D. Percussion vibration and drainage
Correct Answer: A
Rationale: Closed chest drainage is used post-lobectomy to remove air and fluid from the pleural space, promoting lung re-expansion.
The nurse is assessing a client with a history of diabetes mellitus who is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect?
- A. Slow, shallow respirations.
- B. Fruity breath odor.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: B
Rationale: fruity breath odor is a classic sign of DKA due to the presence of acetone
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase levels, particularly above 3 times the normal range, confirm acute pancreatitis due to pancreatic enzyme release.
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months, so a 7-pound newborn would weigh approximately 14 pounds.