Nokea
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
- A. Take at least 2 weeks off from work.
- B. You will need another chest x-ray in 6 weeks.
- C. Take a longer temperature range of time.
- D. Complete all of the antibiotic even if your findings decrease.
Correct Answer: D
Rationale: Complete all of the antibiotic even if your findings decrease. Finishing the full antibiotic course prevents recurrence and resistance.
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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
A 67-year-old man following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
The nurse should
- A. change the position of his hand.
- B. check his grip strength in both hands.
- C. notify the physician.
- D. instruct the patient to exercise his fingers.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatory changes (2) part of assessment, but doesn't indicate status of circulation (3) correct-absent or weak pulse or numbness could indicate problem with circulation, anticoagulants and vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatory changes
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
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.
A client is admitted with a tentative diagnosis of bladder cancer. Which finding most likely contributed to the development of bladder cancer?
- A. Two PPD cigarette use for 25 years
- B. Frequent urinary tract infections
- C. Employment in the textile industry
- D. A history of renal calculi
Correct Answer: A
Rationale: Cigarette smoking is a significant risk factor for bladder cancer due to the exposure to carcinogenic chemicals excreted in urine. Answer A (two packs per day for 25 years) is the most likely contributor. Answers B, C, and D are less directly associated with bladder cancer development.