Nokea
The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify?
- A. Diabetes
- B. Age
- C. Exercise level
- D. Dietary preferences
Correct Answer: B
Rationale: Age is a non-modifiable risk factor for atherosclerosis, as the risk increases with advancing age due to cumulative vascular changes. Diabetes, exercise level, and dietary preferences can be managed or modified to reduce risk, making age the correct answer.
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The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?
- A. Atrial fi brillation
- B. Ventricular tachycardia.
- C. Premature ventricular contractions (PVCs).
- D. Third-degree heart block.
Correct Answer: C
Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
- A. Pinkish red.
- B. Dark yellow-orange.
- C. Clear.
- D. Green.
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?
- A. Uncrossed scarring.
- B. Decreased melanin and melanocytes.
- C. Decreased healing.
- D. Increased immunocompetence.
Correct Answer: C
Rationale: Older adults have slower wound healing due to reduced collagen synthesis and cellular turnover, increasing the risk of delayed recovery post-surgery.
A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
A 250-lb male client recovering from general anesthesia has the following assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/minute; tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
- A. Recovering as expected from the anesthesia and continues monitoring him.
- B. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his I.V. infusion.
- C. In the early stages of malignant hyperthermia and obtains emergency medications and notification.
- D. In pain and offers him pain medication.
Correct Answer: C
Rationale: Tachycardia, hypotension, tachypnea, and muscle rigidity suggest malignant hyperthermia, a life-threatening reaction to anesthesia. Immediate action, including emergency medications like dantrolene, is required.