Nokea
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the most concerning?
- A. Pain and pallor in one foot
- B. Pain in both knees
- C. Splinter hemorrhages in the nail beds
- D. Temperature of 38.2°C (100.8°F)
Correct Answer: A
Rationale: Pain and pallor in one foot suggest an embolic event, a serious complication of infective endocarditis that could lead to tissue ischemia or infarction, requiring urgent intervention. Knee pain, splinter hemorrhages, and mild fever are less immediately threatening.
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The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63 mmHg, HCO3 23, and oxygenation saturation (SaO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?
- A. tuberculosis (TB)
- B. pneumonia
- C. pleural effusion
- D. hypoxia
Correct Answer: D
Rationale: Low PO2 (63 mmHg) and SaO2 (93%) indicate hypoxia, despite normal pH, PCO2, and HCO3. TB, pneumonia, or pleural effusion may cause hypoxia but are not the direct etiology shown by ABGs. Physiological Adaptation
The nurse monitors a client who has followed a vegan diet for several years. Which client statement would indicate a possible complication resulting from a vegan diet?
- A. I have had some visual disturbances while driving at night.
- B. I have had trouble falling asleep over the past few months.
- C. Scaly patches of skin are developing on my elbows and knees.
- D. Sometimes my hands and feet get a tingling sensation.
Correct Answer: A
Rationale: Night vision disturbances suggest vitamin A deficiency, common in vegan diets lacking sufficient beta-carotene sources. Insomnia, scaly skin, and tingling are less specific to vegan diet complications, potentially relating to other causes like stress or neuropathy.
In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?
- A. Place extra padding under the mother to absorb blood from the delivery.
- B. Cut the umbilical cord using sterile scissors.
- C. Suction the baby's mouth and nose.
- D. Wrap the baby in a clean blanket to preserve warmth.
Correct Answer: C
Rationale: Suctioning the baby's mouth and nose first ensures a clear airway, critical for newborn respiration. Other actions follow based on the situation. Safety and Infection Control
Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
- A. Complete all the antibiotics even if your child is feeling better
- B. Cool liquids and soft diet are recommended
- C. Keep your child home from daycare for at least a week
- D. Replace your child’s toothbrush 24 hours after starting antibiotics
- E. Throat lozenges may soothe your child’s sore throat
Correct Answer: A,B,D
Rationale: Completing antibiotics prevents resistance, cool liquids/soft foods ease swallowing, and replacing the toothbrush prevents reinfection. A week-long daycare exclusion is excessive (24-48 hours post-antibiotics is sufficient), and lozenges are unsafe for a 2-year-old due to choking risk.