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Which finding would the nurse expect to see in a patient with a hemoglobin level of 8 g/dL? Select all that apply.
- A. Palpitations.
- B. Conjunctival pallor.
- C. Sternal tenderness.
- D. Heart rate of 104 beats/min.
Correct Answer: B,D
Rationale: Conjunctival pallor and increased heart rate (104 beats/min) are expected in anemia due to reduced oxygen-carrying capacity and compensatory tachycardia.
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The nurse provides education regarding daily activities to a patient with thrombocytopenia. Which activity identified by the patient indicates understanding of the teaching?
- A. Flossing using thick tape floss.
- B. Shaving using an electric razor.
- C. Wearing flip-flops to go walking.
- D. Brushing using a stiff-bristle toothbrush.
Correct Answer: B
Rationale: Shaving using an electric razor reduces the risk of cuts and bleeding, appropriate for a patient with thrombocytopenia due to low platelet counts.
Which manifestation is related to target organ disease from hypertension? Select all that apply.
- A. Anemia.
- B. Aneurysm.
- C. Proteinuria.
- D. Pneumonia.
- E. Transient ischemic attack.
Correct Answer: B,C
Rationale: Aneurysm and proteinuria are manifestations of target organ damage from hypertension, affecting arteries and kidneys, respectively.
A patient's arterial blood gas (ABG) results include a pH of 7.32, a PaCO2 of 56 mm Hg, and an HCO3 of 24 mEq/L. Which acid-base imbalance would the nurse use when developing the patient's plan of care?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Respiratory acidosis is characterized by low pH (7.32) and high PaCO2 (56 mm Hg), with normal HCO3 indicating no metabolic compensation.
The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?
- A. Drinks 14 glasses of water daily.
- B. Shaves once a day using an electric razor.
- C. Uses an alcohol-based mouthwash twice a day.
- D. Brushes teeth with a soft-bristle toothbrush twice a day.
Correct Answer: C
Rationale: Using alcohol-based mouthwash can irritate oral mucosa and cause bleeding in thrombocytopenia, indicating a need for further teaching.
The nurse provides discharge teaching to a patient with venous leg ulcers. Which statement made by the patient indicates the need for further education?
- A. I will take a walk daily.
- B. I will try to lose at least 20 pounds.
- C. I will put on my stockings after I get out of bed each day.
- D. I will not wear knee-high socks that are tight around my calf.
Correct Answer: D
Rationale: Not wearing tight knee-high socks is correct, as tight clothing can impede circulation; the statement suggests misunderstanding, indicating a need for further education.