Nokea
When administering a tuberculin skin test, the nurse should insert the needle at a:
- A. 15° angle
- B. 30° angle
- C. 45° angle
- D. 90° angle
Correct Answer: A
Rationale: A 15° angle is used for intradermal injections like the tuberculin skin test to ensure proper placement in the dermis.
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Which client is at greatest risk for a caesarean section due to cephalopelvic disproportion (CPD)?
- A. A 25-year-old gravida 2, para 1
- B. A 30-year-old gravida 3, para 2
- C. A 17-year-old gravida 1, para 0
- D. A 32-year-old gravida 1, para 0
Correct Answer: C
Rationale: A 17-year-old primigravida is at higher risk for CPD due to a potentially underdeveloped pelvis, increasing the likelihood of cesarean delivery.
A client with cirrhosis has developed signs of heptorenal syndrome. Which diet is most appropriate for the client at this time?
- A. High protein, moderate sodium
- B. High carbohydrate, moderate sodium
- C. Low protein, low sodium
- D. Low carbohydrate, high protein
Correct Answer: C
Rationale: Low protein and low sodium diets reduce the burden on the liver and kidneys in hepatorenal syndrome.
The nurse is completing admission on a client with possible esophageal cancer. Which finding would not be common for this diagnosis?
- A. Foul breath
- B. Dysphagia
- C. Diarrhea
- D. Chronic hiccups
Correct Answer: C
Rationale: Esophageal cancer commonly presents with dysphagia, foul breath (due to tumor necrosis), and chronic hiccups (from diaphragmatic irritation). Diarrhea is not typically associated with esophageal cancer.
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
Which one of the following symptoms is common in the client with duodenal ulcers?
- A. Vomiting shortly after eating
- B. Epigastric pain following meals
- C. Frequent bouts of diarrhea
- D. Presence of blood in the stools
Correct Answer: B
Rationale: Duodenal ulcers typically cause epigastric pain 1-3 hours after meals, relieved by food or antacids.