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What does a nurse assess postoperatively in a client with a nasal fracture?
- A. Allergic reaction
- B. Extreme sense of smell
- C. Airway obstruction
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.
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A client is admitted for a spelenectomy. What problem is the nurse aware that could develop?
- A. Infection
- B. Urinary retention
- C. Congestive heart failure
- D. Viral hepatitis
Correct Answer: A
Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening.
B: Urinary retention is not a typical complication of a splenectomy.
C: Congestive heart failure is not directly related to a splenectomy.
D: Viral hepatitis is not a common complication of a splenectomy.
Severe and extensive hemolysis causes which of the ff?
- A. Leg ulcers
- B. Shock
- C. Priapism
- D. Compromised growth
Correct Answer: B
Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.
A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
- A. Fresh fruits
- B. Dairy products
- C. Lean red meats
- D. Breads and cereals
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern.
Incorrect choices:
A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem.
C: Making accurate interpretations of data comes after data collection and analysis, not as the first step.
D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
- A. Positive ELISA and Western blot tests
- B. Evidence of extreme weight loss and high fever
- C. Identification of an associated opportunistic infection
Correct Answer: A
Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.