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When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
- A. Drainage on the surgical dressing
- B. Complaints of neck pain
- C. Bleeding from the mouth
- D. Swelling in the posterior neck
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.
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All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT
- A. low birth weight.
- B. placing the child on his back to sleep.
- C. young maternal age.
- D. maternal smoking during pregnancy.
Correct Answer: B
Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
- A. Wait until the client is placed on the delivery table and administer the medication
- B. Question the order
- C. Give the medication IM during the delivery to prevent pain from the episiotomy
- D. Give the medication as ordered
Correct Answer: B
Rationale: Administering meperidine 10 minutes before delivery risks neonatal respiratory depression, so the nurse should question the order.
The physician has prescribed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:
- A. Hypertension
- B. Hyperthermia
- C. Hypotension
- D. Urinary retention
Correct Answer: A
Rationale: Tyramine with MAOIs like tranylcypromine can cause a hypertensive crisis.
Which client is at the greatest risk of developing colon cancer?
- A. a 83-year-old Hispanic female with a past history of cholecystectomy
- B. a 62-year-old African American male with a past history of diabetes
- C. a 70-year-old Caucasian male with a past history of cancer treated with chemotherapy
- D. a 42-year-old Asian female who follows a high-fiber diet
Correct Answer: C
Rationale: Previous cancer history, especially treated with chemotherapy, increases colon cancer risk due to potential genetic or environmental factors. Age over 50 also elevates risk.
When examining an 80-year-old client with chronic COPD receiving home health care, the nurse notes that over the previous 48 hours the client has developed scattered painful pustular lesions on the right arm near the elbow (see photo), on the back of the neck, the face, and on both legs. Which of the following does the nurse suspect is the most likely cause of the lesions?
- A. Psoriasis
- B. Herpes zoster
- C. MRSA
- D. Contact dermatitis
Correct Answer: C
Rationale: Painful pustular lesions in a client with chronic illness suggest MRSA (C), a common healthcare-associated infection. Psoriasis (A) presents with scaly plaques, herpes zoster (B) follows a dermatomal pattern, and contact dermatitis (D) is typically itchy, not pustular.