Nokea
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
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A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
- A. Taking sitz baths several times a day.
- B. Applying a moist heat pack to the wound.
- C. Performing perineal irrigations.
- D. Packing the wound with sterile gauze.
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
- A. Maintain sterile technique.
- B. Use a mask, gloves, and a gown when assisting with the procedure.
- C. Place the specimen in a container and send it to the laboratory when someone is available to take it.
- D. Call for a laboratory technician to assist the physician.
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.
When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle?
- A. Dysmenorrhea.
- B. Metrorrhagia.
- C. Oligomenorrhea.
- D. Menorrhagia.
Correct Answer: C
Rationale: Thyrotoxicosis increases metabolism, which can lead to decreased menstrual flow or oligomenorrhea (infrequent menstruation). Dysmenorrhea (painful periods), metrorrhagia (irregular bleeding), and menorrhagia (heavy bleeding) are less commonly associated with thyrotoxicosis.
The nurse is caring for a client who has been diagnosed with macular degeneration. Which of the following images represent the visual field of a client with macular degeneration?
- A. Qstn 14-A Visual.png
- B. Qstn 14-B Visual.png
- C. Qstn 14-C Visual.png
- D. Qstn 14-D Visual.png
Correct Answer:
Rationale: Macular degeneration causes central vision loss, so the image would show a blurred or dark central area with intact peripheral vision. Specific image selection is not applicable here due to lack of image options.
The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.