Nokea
Which of the following is a risk factor for hypovolemic shock?
- A. Hemorrhage.
- B. Antigen-antibody reaction.
- C. Gram-negative bacteria.
- D. Vasodilation.
Correct Answer: A
Rationale: Hemorrhage is a primary cause of hypovolemic shock, as it reduces circulating blood volume. Antigen-antibody reactions cause anaphylactic shock, gram-negative bacteria cause septic shock, and vasodilation is a feature of distributive shock.
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The nurse is preparing to administer prescribed medications to a client via a nasogastric tube connected to low-intermittent suction. The nurse should take which appropriate action? Select all that apply.
- A. Position the client in Trendelenburg position.
- B. Verify correct placement of the tube before medication administration.
- C. Turn off the suction during medication administration.
- D. Resume low-intermittent wall suction immediately after medication administration.
- E. Irrigate the nasogastric tube (NGT) with sterile water.
Correct Answer: B,C
Rationale: Verifying tube placement and turning off suction ensure safe medication administration; Trendelenburg is inappropriate, and sterile water is not required.
The nurse using healing touch affects a client's pain primarily through:
- A. Energy fields.
- B. Touch therapy.
- C. Massage.
- D. Hypnosis.
Correct Answer: A
Rationale: Healing touch primarily uses energy fields to promote relaxation and pain relief, distinct from massage, physical touch therapy, or hypnosis.
Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
- A. Eat animal protein and dark green, leafy vegetables and eggs.
- B. Avoid exposure to others with acute infections.
- C. Practice yoga and meditation to decrease stress and anxiety.
- D. Get 8 hours of sleep at night and take naps during the day.
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.