Nokea
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.
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A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?
- A. Vertigo.
- B. Bell's palsy.
- C. Hypoventilation.
- D. Loss of gag reflex.
Correct Answer: C
Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?
- A. A condition.
- B. Jaundice.
- C. Generalized edema.
- D. Dark, scanty urine.
Correct Answer: D
Rationale: Dark, scanty urine indicates renal failure, a potential complication of compartment syndrome due to myoglobin release.
The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
- A. For administration of oxygen.
- B. To promote formation of lung scar tissue.
- C. To insert antibiotics into the pleural space.
- D. To remove air and fluid.
Correct Answer: D
Rationale: A chest tube in pneumothorax removes air and fluid from the pleural space, restoring lung expansion. It is not used for oxygen, scar tissue, or antibiotics.