Nokea
Nurses' Notes
Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.
The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
- A. Pneumonia
- B. Lung cancer
- C. Flu
- D. Chronic obstructive pulmonary disease (COPD)
- E. Chronic bronchitis
Correct Answer: B,E
Rationale: Lung cancer and chronic bronchitis are associated with clubbed nails due to chronic hypoxemia, unlike pneumonia or flu.
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The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
- A. Report reoccurring visual signs of retinal detachment.
- B. Maintain the head in one postoperative position.
- C. Watch for signs of infection in the surgical eye.
- D. Ambulate to the bathroom with assistance.
Correct Answer: A
Rationale: Reporting signs of retinal detachment is critical to ensure the success of the scleral buckling procedure.
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.
A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?
- A. Teach about compliance to reduce blood pressure.
- B. Provide rest periods and portable oxygen.
- C. Maintain continuous monitoring of heart rate and rhythm.
- D. Administer nitroglycerin daily.
Correct Answer: A
Rationale: Reducing blood pressure decreases cardiac workload, preventing cardiomegaly and improving contractility.
The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?
- A. Ensure the IV solution is infusing at the prescribed rate.
- B. Listen to lung sounds.
- C. Notify the healthcare provider of the findings.
- D. Check under the back for evidence of bleeding.
Correct Answer: D
Rationale: Checking for bleeding addresses potential hypovolemic shock, indicated by low blood pressure and tachycardia, prioritizing over IV rate or notification.