Nokea
Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will:
- A. Demonstrate a decrease in fluid retention related to ascites.
- B. Verbalize the importance of reporting bleeding gums or bloody stools.
- C. Limit use of alcohol to two to three drinks per week.
- D. Restrict activity to within the home to prevent disease transmission.
Correct Answer: B
Rationale: Reporting bleeding (B) indicates awareness of complications like coagulopathy. Ascites (A) is more relevant to cirrhosis. Alcohol (C) should be avoided entirely. Restricting activity to home (D) is unnecessary for hepatitis B or C.
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Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
- A. Lying on the side with legs extended.
- B. Lying on the abdomen with toes pointed inward.
- C. Leaning over the edge of a low table with hips flexed.
- D. Standing upright with the feet one shoulder-width apart.
Correct Answer: B
Rationale: The ventrogluteal site is best accessed when the client lies on their abdomen with toes pointed inward, as this position relaxes the gluteal muscles and minimizes discomfort during injection. The other positions do not optimally relax the muscle or provide access to the ventrogluteal site.
What is the nurse's priority for a client with an altered level of consciousness?
- A. Assess airway.
- B. Check reflexes.
- C. Monitor urine output.
- D. Perform a pain assessment.
Correct Answer: A
Rationale: Assessing the airway is the priority to ensure adequate oxygenation in a client with altered consciousness.
A client receives a thrombolytic agent. The expected outcome of this drug therapy includes:
- A. Improved cerebral perfusion
- B. Decreased vascular permeability
- C. Dissolved emboli
- D. Prevention of further cerebral hemorrhage
Correct Answer: C
Rationale: Thrombolytic agents (e.g., alteplase) dissolve existing clots, such as emboli in pulmonary embolism or arterial occlusion, restoring blood flow. They do not improve cerebral perfusion, decrease vascular permeability, or prevent cerebral hemorrhage (they increase bleeding risk).