Nokea
Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.
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The nurse is discharging a client newly diagnosed with restrictive airway disease (asthma). Which statement indicates the client understands the discharge instructions?
- A. I will call 911 if my medications don't control an attack.
- B. I will wash my bedding in warm water.
- C. I can still eat at the Chinese restaurant when I want.
- D. If I get a headache, I should take a nonsteroidal anti-inflammatory drug.
Correct Answer: A
Rationale: Calling 911 for uncontrolled asthma (A) shows understanding of emergency action. Warm water (B) is insufficient (hot water needed), Chinese food (C) may contain MSG, and NSAIDs (D) can trigger asthma.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach?
- A. Demonstrate the proper method of gargling with normal saline.
- B. Perform voice exercises for 30 minutes three (3) times a day.
- C. Explain that a lighted instrument will be placed in the throat to biopsy the area.
- D. Teach the client to self-examine the larynx monthly.
Correct Answer: C
Rationale: Laryngoscopy with biopsy (C) diagnoses laryngeal cancer, requiring client education. Gargling (A), voice exercises (B), and self-examination (D) are not diagnostic.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.