Nokea
Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
- A. Excess Fluid Volume
- B. Risk for Aspiration
- C. Disturbed Body Image
- D. Urinary Retention
Correct Answer: C
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable.
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A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
- A. nucleoside reverse transcriptase inhibitors
- B. protease inhibitors
- C. HIV fusion inhibitors
- D. all of the above.
Correct Answer: D
Rationale: All of the choices are anti-HIV drugs.
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct Answer: A
Rationale: An oropharyngeal airway is measured from the corner of the client's mouth, to the tragus of the ear.
A nurse is caring for a retired MD. The MD asks the question, 'What type of cells create exocrine secretions?'
- A. alpha cells
- B. beta cells
- C. acinar cells
- D. plasma cells
Correct Answer: C
Rationale: Acinar cells create exocrine secretions.
Which sign might the nurse see in a client with a high ammonia level?
- A. coma
- B. edema
- C. hypoxia
- D. polyuria
Correct Answer: A
Rationale: Coma might be seen in a client with a high ammonia level.
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids.
- B. administer oxygen.
- C. decrease maternal fluids.
- D. turn the mother.
Correct Answer: C
Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.