Nokea
Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
- A. Tachypnea
- B. Tachycardia
- C. Peripheral edema
- D. Pale, cool extremities
Correct Answer: C
Rationale: Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.
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Bronchoconstriction is a recognised side effect of:
- A. Captopril
- B. Salbutamol
- C. Ibuprofen
- D. Paracetamol
Correct Answer: B
Rationale: Salbutamol can cause bronchoconstriction in some cases due to its paradoxical effect, especially if overused or misused.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
- A. I wake up to go to the bathroom at night.
- B. My shoes fit tighter by the end of the day.
- C. I seem to be feeling more anxious lately.
- D. I drink at least eight glasses of water a day.
Correct Answer: B
Rationale: Tight-fitting shoes by the end of the day suggest fluid retention (edema), a common sign of cardiovascular or renal issues.
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse?
- A. Glucose of 350 mg/dl
- B. White blood cell count of 15,000 mm3
- C. Blood PH of 7.30
- D. Potassium of 2.5 mEq/L
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L is dangerously low and must be corrected immediately to prevent cardiac arrhythmias.
Respiratory pathogens in the immunosuppressed include:
- A. Staphylococcus aureus
- B. Legionella
- C. Pneumocystis carinii
- D. Chlamydia
Correct Answer: C
Rationale: Pneumocystis carinii: Pneumocystis carinii pneumonia is a life-threatening infection in immunocompromised patients, especially those with HIV/AIDS or undergoing immunosuppressive therapy.
The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity?
- A. Seizures
- B. Vomiting
- C. Bradypnea
- D. Tachycardia
Correct Answer: B
Rationale: Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be slower, not faster.