Nokea
Which assessment is critical for a client receiving thrombolytic therapy?
- A. Blood glucose.
- B. Blood pressure.
- C. Temperature.
- D. Cholesterol level.
Correct Answer: B
Rationale: Blood pressure is critical to monitor during thrombolytic therapy to prevent hemorrhagic complications.
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The nurse is preparing an educational program on breast cancer for women at an African American community center. What information is important for the nurse to consider for the discussion?
- A. African American women have the lowest rate of breast cancer.
- B. Most African American women are diagnosed early in the disease process.
- C. Breast cancer concerns vary between socioeconomic levels of African American women.
Correct Answer: C
Rationale: Breast cancer incidence and outcomes can vary significantly across socioeconomic levels due to differences in access to healthcare, screening, and education. This is critical for tailoring an effective educational program. African American women do not have the lowest rate of breast cancer, and they are often diagnosed at later stages, not early.
A nurse is caring for a client with lung cancer who develops syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory finding should the nurse expect?
- A. Serum sodium of 128 mEq/L.
- B. Serum potassium of 5.5 mEq/L.
- C. Serum calcium of 11.0 mg/dL.
- D. Serum glucose of 200 mg/dL.
Correct Answer: A
Rationale: SIADH causes water retention, diluting serum sodium, so a low sodium level (128 mEq/L) is expected due to the inappropriate secretion of antidiuretic hormone.
The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply.
- A. Avoiding being silhouetted against strong light.
- B. Not blocking out the person's view of the speaker's mouth.
- C. Facing the client when talking.
- D. Having bright light behind so the individual can see.
- E. Ensuring the client is familiar with the subject material before discussing.
- F. Talking to the client while doing other nursing procedures.
Correct Answer: A,B,C
Rationale: To facilitate lip-reading, the nurse should avoid strong backlighting, not block the view of the mouth, and face the client directly to ensure clear visibility of facial expressions and lips.
The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to:
- A. Locate the program at an existing government facility.
- B. Integrate folk beliefs and traditions into the content.
- C. Prepare materials in the primary language of the program sponsor.
- D. Exclude community leaders from initial planning efforts.
Correct Answer: B
Rationale: Integrating folk beliefs and traditions ensures the program is culturally relevant and increases acceptance and effectiveness among socioeconomically disadvantaged populations.
A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
- A. Initiate gastric lavage.
- B. Maintain body temperature.
- C. Administer 100% oxygen by mask.
- D. Obtain a psychiatric referral.
Correct Answer: C
Rationale: Administering 100% oxygen displaces carbon monoxide from hemoglobin, the priority in poisoning. Gastric lavage, temperature maintenance, and psychiatric referrals are secondary.