Nokea
Which action is contraindicated in the client with epiglottis?
- A. Ambulation
- B. Oral airway assessment using a tongue blade
- C. Placing a blood pressure cuff on the arm
- D. Checking the deep tendon reflexes.
Correct Answer: B
Rationale: Using a tongue blade can trigger airway obstruction in epiglottitis, making it contraindicated.
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The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?
- A. Complaint of dry mouth
- B. Loss of 1 inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally on chest auscultation suggest fluid in the lungs, which could indicate serious conditions like heart failure or pneumonia, requiring immediate attention. Dry mouth, height loss, and stiffened joints are common in aging but less urgent.
The nurse is doing a digital removal of stool for a client with a large fecal impaction resulting from opioid use when the client feels faint, and assessment of vital signs shows a marked decrease in pulse. Which of the following is the most likely reason for the change in pulse rate?
- A. Stimulation of the vagus nerve
- B. Onset of shock
- C. Internal bleeding
- D. Anxiety
Correct Answer: A
Rationale: Digital stool removal can stimulate the vagus nerve (A), causing bradycardia and faintness. Shock (B), bleeding (C), or anxiety (D) are less likely.
The nurse has an order to give 500 mL of 0.45% NS over 12 hours. The IV set has a drop factor of 10. How many gtts/min should the client receive? Fill in the blank.
Correct Answer: 7
Rationale: Rate = 500 mL ÷ 12 hr = 41.67 mL/hr. Drops/min = (41.67 mL/hr × 10 gtts/mL) ÷ 60 min = 6.94 gtts/min, rounded to 7 gtts/min.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria is a classic sign of right-sided heart failure due to fluid redistribution when lying down.
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
- A. Gingival hypertrophy
- B. Hirsutism
- C. Hypertrophy of facial subcutaneous tissue
- D. Dementia
- E. Anemia
Correct Answer: A,B,E
Rationale: Phenytoin's long-term effects include gingival hypertrophy (A), hirsutism (B), and anemia (E). Facial hypertrophy (C) and dementia (D) are not associated with phenytoin.