Nokea
Which of the following increases the risk of having a large abdominal aortic aneurysm rupture?
- A. Anemia
- B. Dehydration
- C. High blood pressure
- D. Hyperglycemia
Correct Answer: C
Rationale: High blood pressure increases wall stress in a large abdominal aortic aneurysm, elevating the risk of rupture per Laplace's law (wall tension ˆ pressure × radius). Anemia, dehydration, and hyperglycemia do not directly increase rupture risk.
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The nurse administers theophylline (TheoDur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
- A. Suppression of the client's respiratory infection.
- B. Decrease in bronchial secretions.
- C. Relaxation of bronchial smooth muscle.
- D. Thinning of tenacious, purulent sputum.
Correct Answer: C
Rationale: Theophylline relaxes bronchial smooth muscle, relieving bronchospasm in COPD. It does not suppress infection, reduce secretions, or thin sputum.
The client with Ménière'sdisease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modification for the client's disease is:
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. Low fat.
Correct Answer: A
Rationale: A low-sodium diet is recommended for Ménière'sdisease to reduce fluid retention in the inner ear, which can decrease the frequency and severity of vertigo attacks.
There has been an increase in medication errors and errors in ordering laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply.
- A. When a medication order or critical lab result is received with the current or critical lab result is received.
- B. When any verbal or phone order is received.
- C. Whenever a written order or printed critical test result is received.
- D. When the unit secretary takes a phone order.
- E. When the agency uses computerized health care records.
Correct Answer: A,B,D
Rationale: Read-back procedures are required for verbal, phone, or critical result communications to ensure accuracy, especially when relayed through staff like unit secretaries.
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?
- A. Encouraging regular ambulation.
- B. Promoting bowel rest.
- C. Maintaining current weight.
- D. Decreasing episodes of rectal bleeding.
Correct Answer: B
Rationale: Promoting bowel rest is the priority during a Crohn's exacerbation to reduce inflammation and symptoms. Ambulation, weight maintenance, and reducing bleeding are secondary to resting the bowel. CN: Physiological adaptation; CL: Synthesize
The nurse is assessing a client with age-related cataracts. Which of the following assessment findings would support this diagnosis of age-related cataracts?
- A. peripheral vision loss
- B. central vision loss
- C. difficulty seeing at night, especially while driving
- D. blurred vision with headache
Correct Answer: C
Rationale: Age-related cataracts often cause difficulty seeing at night, particularly while driving, due to lens opacity scattering light. Peripheral vision loss is more associated with glaucoma, central vision loss with macular degeneration, and blurred vision with headache is typical of angle-closure glaucoma.