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Which of the following is the most important goal of nursing care for a client who is in shock?
- A. Manage fluid overload.
- B. Manage increased cardiac output.
- C. Manage inadequate tissue perfusion.
- D. Manage vasoconstriction of vascular beds.
Correct Answer: C
Rationale: Shock is characterized by inadequate tissue perfusion due to insufficient blood flow. The primary nursing goal is to restore perfusion to vital organs through fluid resuscitation, medications, or other interventions. Fluid overload, increased cardiac output, and vasoconstriction are not primary concerns.
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Which of the following is not a risk factor for the development of atherosclerosis?
- A. A family history of early heart attack.
- B. Late onset of puberty.
- C. Total blood cholesterol level greater than 220 mg/dL.
- D. Elevated fasting blood glucose concentration.
Correct Answer: B
Rationale: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
A 62-year-old male client with prostate cancer is scheduled for a radical prostatectomy. He expresses concern about how the surgery will affect his sexual function. The nurse's best response is to:
- A. Explain that sexual function will not be affected.
- B. Discuss that erectile dysfunction is a possible side effect.
- C. Suggest that he avoid sexual activity post-surgery.
- D. Assure him that libido will return immediately after recovery.
Correct Answer: B
Rationale: Radical prostatectomy often affects the nerves responsible for erections, making erectile dysfunction a possible side effect. Discussing this honestly prepares the client for potential outcomes and management options.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply.
- A. To ensure efficient and accurate communication.
- B. To prevent medication errors.
- C. To ensure client safety.
- D. To make it easier for clients to understand the medication orders.
- E. To make data entry into a computerized health record easier.
Correct Answer: A,B,C
Rationale: Eliminating dangerous abbreviations ensures clear communication, prevents medication errors, and enhances client safety by reducing misinterpretations. Client understanding and data entry ease are secondary benefits.
The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.