Nokea
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.
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A 69-year-old man is receiving dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician?
- A. PT 12 seconds and Hgb 15 g/dL.
- B. BUN 18 mg/dL and creatinine 1.0 mg/dL.
- C. K⺠3.4 mEq/L and CA⺠5/5 mEq/L.
- D. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.
Correct Answer: C
Rationale: normal Kâ 3.5-5.0 mEq/L, normal Ca 4.5-5.3 mEq/L, indicates hypokalemia and hypercalcemia
Under the supervision of the registered nurse, a student nurse is changing the dressing of a 49-year-old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require an intervention by the registered nurse?
- A. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
- B. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
- C. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
- D. The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer: C
Rationale: should clean from insertion site outward toward outer abdomen
The nurse is caring for a client with a history of Cushing’s syndrome.
- A. Which symptom is expected in a client with Cushing’s syndrome?
- B. Weight loss and fatigue.
- C. Moon face and truncal obesity.
- D. Hypotension and bradycardia.
- E. Polyuria and thirst.
Correct Answer: B
Rationale: Moon face and truncal obesity result from cortisol excess in Cushing’s syndrome. Weight loss, hypotension, and polyuria are more typical of Addison’s disease or diabetes insipidus.
An adult is admitted through the outpatient department for elective surgery today. The client is coughing and sneezing and has a temperature of 100.6°F. What should the nurse do next?
- A. Prepare the client for surgery as scheduled
- B. Explain to the client that a cold increases risks during surgery and ask if he/she is willing to assume those risks
- C. Call the physician before continuing preparations for surgery
- D. Ask what type of anesthesia the client is receiving
Correct Answer: C
Rationale: Infection increases surgical risks; notifying the physician allows for evaluation and possible postponement.
The nurse is caring for a client with a history of anaphylaxis.
- A. Which instruction is most important for a client with a history of anaphylaxis?
- B. Carry an epinephrine auto-injector at all times.
- C. Avoid over-the-counter medications.
- D. Wear loose-fitting clothing.
- E. Monitor blood pressure daily.
Correct Answer: A
Rationale: Carrying an epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Avoiding medications, wearing loose clothing, and monitoring blood pressure are less urgent.