Nokea
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
- A. Excessive thrombosis and bleeding
- B. Clotting of the mucous membranes
- C. Increase in platelet count
- D. Excessive red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.
You may also like to solve these questions
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility to a normal level.
- C. Promote independent living without assistance.
- D. Restore full visual function.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. For a client who had a left hemispheric CVA, the left hemisphere is responsible for language and speech functions. Therefore, focusing on establishing effective communication is crucial in the rehabilitation program. It targets the specific deficits caused by the CVA and aims to improve the client's quality of life. Increasing mobility to a normal level (B) is important but may not be the priority in this case. Promoting independent living without assistance (C) is a broad goal that may encompass various aspects beyond communication. Restoring full visual function (D) is not directly related to a left hemispheric CVA.
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Limit salt intake.
- B. Avoid consuming alcohol.
- C. Engage in light exercise regularly.
- D. Rest frequently throughout the day.
Correct Answer: D
Rationale: The correct answer is D: Rest frequently throughout the day. For a client with hepatitis B, rest is essential to allow the body to recover and heal. Hepatitis B can cause fatigue and weakness, so resting frequently helps to conserve energy and support the immune system in fighting the infection. Limiting salt intake (Choice A) is not directly related to managing hepatitis B. Avoiding alcohol (Choice B) is important but more for liver health in general, not specifically for hepatitis B. Engaging in light exercise regularly (Choice C) may be beneficial for overall health, but during active hepatitis B infection, rest is more crucial.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
A nurse is planning a teaching session about hysterosalpingography for a client who has a diagnosis of infertility. The nurse should include which of the following information in the teaching plan?
- A. The client might experience shoulder pain following the procedure.
- B. The client might experience nausea and vomiting after the procedure.
- C. The client will need to stay in bed for 24 hours post-procedure.
- D. The client should avoid drinking fluids before the procedure.
Correct Answer: A
Rationale: The correct answer is A: The client might experience shoulder pain following the procedure. This is because hysterosalpingography involves the injection of contrast dye into the uterus and fallopian tubes, which can cause referred pain to the shoulder due to irritation of the diaphragm. This information is crucial for the client to be aware of potential side effects.
The other choices are incorrect:
B: The client might experience nausea and vomiting after the procedure - This is not a common side effect of hysterosalpingography.
C: The client will need to stay in bed for 24 hours post-procedure - There is no requirement for prolonged bed rest after the procedure.
D: The client should avoid drinking fluids before the procedure - In fact, it is recommended to drink plenty of fluids before the procedure to help flush out the contrast dye.