Nokea
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
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A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
Which nursing action is important in preventing cross-contamination?
- A. Change gloves immediately after use.
- B. Stand 2 feet from the client.
- C. Speak minimally when in the room.
- D. Wear long-sleeved shirts.
Correct Answer: A
Rationale: Changing gloves immediately after use prevents cross-contamination by removing potential pathogens from the nurse's hands before touching other surfaces or clients. The other actions are less effective in preventing contamination.
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
- A. Administer an antidiarrheal as ordered.
- B. Encourage a high-fiber diet.
- C. Schedule meals earlier in the day.
- D. Provide a bedside commode.
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.