Nokea
Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
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The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
- A. Increase the irrigation flow rate.
- B. Notify the physician.
- C. Administer a diuretic as ordered.
- D. Stop the irrigation and assess the catheter.
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms
A client confides in the nurse that a close friend recently died from pancreatic cancer. The client asks what the risk factors are for pancreatic cancer. The nurse should respond with
- A. Being a female of Asian descent is linked to an increased risk of pancreatic cancer.'
- B. Drinking two or fewer alcoholic beverages per week is linked to an increased risk of pancreatic cancer.'
- C. Past history of acute pancreatitis before age 20 is linked to an increased risk of pancreatic cancer.'
- D. Cigarette smoking is linked to an increased risk for pancreatic cancer.'
Correct Answer: D
Rationale: Cigarette smoking is a well-established risk factor for pancreatic cancer, increasing risk through carcinogenic exposure.
Which of the following is a metabolic, life-threatening adverse reaction to general anesthesia?
- A. hypothermia
- B. hyperthermia
- C. hypoglycemia
- D. hyperglycemia
Correct Answer: B
Rationale: Malignant hyperthermia is a life-threatening reaction to general anesthesia, characterized by rapid temperature increase due to muscle hypermetabolism.
The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?
- A. Bilateral wheezing.
- B. Decreased breath sounds on one side.
- C. Clear, resonant percussion sounds.
- D. Slow, shallow respirations.
Correct Answer: B
Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse