Nokea
The nurse knows which of the following is the most common problem for a client with valvular heart disease?
- A. Altered body image
- B. Difficulty coping
- C. Bradycardia
- D. Decreased cardiac output
Correct Answer: D
Rationale: Valvular disease stenosis or regurgitation slashes flow; decreased cardiac output reigns as pump falters, driving fatigue and dyspnea, the top issue. Body image or coping lag; bradycardia's rare. Nurses peg output drop, targeting meds or surgery, a core fight in this valve-wrecked heart.
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Upon percussion of the midclavicular line from cranial to caudal, you can locate the absolute and relative lung-liver borders. Question: What produces the sound you hear between these two borders?
- A. It is caused by lung tissue
- B. It is caused by liver tissue
- C. It is caused by colon tissue
- D. It is caused by the overlap of lung tissue and liver tissue
Correct Answer: D
Rationale: Lung-liver edge overlap dulls the tap, not pure lung, liver, or colon. Nurses hear this, a chronic border beat.
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site every hour
- B. Educating the client on side effects
- C. Monitoring the client for nausea
- D. Providing warm packs for comfort
Correct Answer: A
Rationale: Chemotherapy drugs administered via peripheral IV can be vesicants, meaning they can cause severe tissue damage if they leak (extravasate) into surrounding tissues. Peripheral lines are more prone to this than central lines due to smaller vein size and less secure placement. Assessing the IV site hourly or per facility policy is the most important action to prevent extravasation, ensuring the line remains patent and no swelling, redness, or pain develops. Early detection allows prompt intervention, like stopping the infusion, to minimize harm. Educating about side effects and monitoring for nausea are key aspects of care but address systemic effects, not the immediate risk of local tissue injury. Warm packs might soothe discomfort but could worsen damage if extravasation occurs. Prioritizing IV site assessment reflects the nurse's role in safety and prevention, critical in oncology where chemotherapy's potency demands vigilant monitoring to protect the client from serious complications.
A female client is being treated for a deep-vein thrombus she developed post-operatively about one week ago and was treated with unfractionated heparin. Today she presents to the clinic with petechiae on bilateral hands and feet. Laboratory results show a platelet count of 42,000/mm³. The nurse is concerned about a drug reaction and anticipates the client has which of the following?
- A. Heparin-induced thrombocytopenia (HIT)
- B. Hemophilia A (classic hemophilia)
- C. Thrombotic thrombocytopenic purpura (TTP)
- D. Sickle cell crisis
Correct Answer: A
Rationale: Heparin can backfire petechiae and a platelet plunge to 42,000/mm³ post-DVT treatment scream HIT, an immune reaction trashing platelets, risking clots. Hemophilia's genetic, not drug-tied. TTP adds fever, neuro signs absent here. Sickle crisis pains, not bleeds like this. Nurses suspect HIT, anticipating heparin cessation and alternatives, a twist in this anticoagulation tale.
Which of the following models calls for a political response to disability?
- A. Social
- B. Medical
- C. Activist
- D. Collaborative
Correct Answer: A
Rationale: Social model demands political fixes disability's a society fail, not body flaw nurses see it push access, not just meds. Medical treats; activist's vague; collaborative teams up, no policy call. It's a chronic shift, environment over anatomy.
Erysipelas
- A. responds to erythromycin
- B. is caused strep pneumoniae
- C. results from microorganism exotoxin production
- D. typically occurs on the neck
Correct Answer: A
Rationale: Erysipelas erythro clears strep pyogenes, not pneumo, toxins, neck-only, or TEN's peel. Nurses dose this chronic red edge.