Nokea
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
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Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.
The fist action by the nurse should be to:
- A. Check the mother's vital signs.
- B. Elevate the foot part of the bed.
- C. Immediately notify the physician.
- D. Massage the mother's uterus and expel any clots.
Correct Answer: D
Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (B), increased vaginal discharge (C), and diaphragmatic pressure (D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.
Most asthmatic attacks respond to Epinephrine (Adrenalin)
Most asthmatic attacks respond to Epinephrine (Adrenalin) and it may be used as a therapeutic agent in the treatment of some allergic conditions because it:
- A. Improves cardiac output due to its positive inotropic effect.
- B. Acts as a hypertensive agent elevating BP.
- C. Dilates the bronchi.
- D. Antagonizes histamine.
Correct Answer: C
Rationale: Epinephrine dilates bronchi, relieving bronchospasm in asthma and allergic reactions.
A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema.
On admission of this patient, which of the following should be assessed first?
- A. blood pressure
- B. skin breakdown
- C. serum potassium
- D. urine output
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.
A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night.
- B. Practice monthly self-breast examination.
- C. Reduce stress.
- D. All of the above.
Correct Answer: D
Rationale: All listed actions—adequate sleep, self-breast exams, and stress reduction—contribute to cancer prevention by supporting immune function, early detection, and overall health. Health Promotion and Management