Nokea
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are classic signs of infection. Redness is caused by inflammation, swelling occurs due to fluid accumulation in response to infection, and induration refers to the hardening of the tissue, which is a result of the body's immune response. Infections can lead to delayed wound healing, increased pain, and other complications. It is essential to address these signs promptly to prevent further complications and promote healing.
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The major pharmacologic action of albuterol sulfate (Proventil HFA) is:
- A. decreasing airway reactivity.
- B. decreasing inflammation and airway obstruction.
- C. improving the action of cilia to sweep trapped mucous upward.
- D. relaxing constricted bronchial smooth muscle.
Correct Answer: D
Rationale: Albuterol acts as a beta-2 agonist, relaxing bronchial smooth muscle to relieve airway constriction.
The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. What is most likely the cause of the weight loss?
- A. Poor appetite
- B. Increased potassium intake
- C. Reduction of edema
- D. Restriction to bed rest
Correct Answer: C
Rationale: The child most likely lost 8 pounds due to a reduction of edema. Acute glomerulonephritis is a condition that can lead to significant fluid retention in the body, causing edema (swelling). When the child was hospitalized and received treatment, such as diuretics, to address the underlying cause of the edema, the excess fluid and weight would be lost. This reduction in edema is the most common reason for weight loss in this scenario, rather than poor appetite, increased potassium intake, or restriction to bed rest.
A patient had a lumbar injury. Which neurological test by the nurse would be affected?
- A. Rhine's test
- B. Pupillary reaction
- C. Romberg's test
- D. Patellar reflex
Correct Answer: C
Rationale: Romberg's test is a neurological test that assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception and vibration sensations. A lumbar injury can affect these dorsal columns, leading to impaired proprioception. Therefore, the Romberg's test would be affected due to the compromised sensory input from the lower extremities. This test usually involves asking the patient to stand with feet together and eyes closed to assess balance and proprioception.
A 12-year-old male adolescent, recently diagnosed with Hodgkin lymphoma, shows left cervical and supraclavicular lymph node involvement and drenching night sweats. Based on Ann Arbor Classification, the patient is classified as
- A. stage IA
- B. stage IB
- C. stage IIA
- D. stage IIB
Correct Answer: D
Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.
The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
- A. Citrus fruits and green leafy vegetables
- B. Bananas and nuts
- C. Coffee and tea
- D. Dairy products
Correct Answer: A
Rationale: Citrus fruits and green leafy vegetables are good sources of vitamin C and non-heme iron, which can help improve iron absorption in individuals with iron deficiency anemia. Bananas and nuts do not have a direct impact on iron absorption. Coffee and tea contain compounds that can inhibit iron absorption. Dairy products, while an important part of a balanced diet, do not specifically aid in improving iron levels. Thus, selecting citrus fruits and green leafy vegetables indicates that the client understands the dietary instructions provided by the nurse to manage iron deficiency anemia.