Nokea
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: In pancreatitis, fluid sequestration into the retroperitoneal space (B) causes hypovolemia, complicating shock management. Intestinal hemorrhage (A), infection (C), and decreased cardiac output (D) are less primary contributors.
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The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
- A. Determine that there will be a latex-safe environment for surgery.
- B. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
- C. Notify the health care providers at the surgery center.
- D. Wear a stainless steel medical alert bracelet into the surgical suite.
- E. Ask to have the surgery at a hospital.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
To prepare the irrigation solution used for removal of cerumen, the nurse should use:
- A. Normal saline.
- B. Sterile water.
- C. Antiseptic solution.
- D. Warm tap water.
Correct Answer: A
Rationale: Normal saline is the preferred solution for ear irrigation, as it is isotonic and safe for the ear canal, minimizing irritation or risk of infection.
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease?
- A. Involvement of a single lymph node.
- B. Involvement of two or more lymph nodes on the same side of the diaphragm.
- C. Involvement of lymph node regions on both sides of the diaphragm.
- D. Diffuse disease of one or more extralymphatic organs.
Correct Answer: A
Rationale: Stage 1A Hodgkin's disease indicates involvement of a single lymph node region without B symptoms (fever, night sweats, weight loss). Higher stages involve multiple nodes or extralymphatic sites.