Nokea
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct Answer: C
Rationale: Acute Pain is most appropriate for the client experiencing acute pancreatitis, as pancreatitis causes severe abdominal pain due to inflammation and autodigestion of the pancreas.
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When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance
- B. When started, therapy must not be interrupted to prevent opportunistic infection
- C. Therapy should be interrupted for one day each month to prevent toxicity
- D. Therapy should be interrupted for one week every three months to prevent toxicity
Correct Answer: A
Rationale: HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge - even taking a dose late. Choice B is incorrect because, when the virus is kept in check with anti-retrovirals, the client's own immune system is able to keep opportunistic infections at bay. Choices C and D are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be prescribed.
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
- A. inspection for visible pulsation.
- B. palpation of thrill.
- C. percussion for dullness.
- D. auscultation of blood pressure.
Correct Answer: B
Rationale: Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.
Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
- A. Ca
- B. K
- C. Na
- D. Cl
Correct Answer: B
Rationale: A potassium level of 2.0 mEq/L is critically low (normal 3.5-5.5 mEq/L), risking cardiac arrhythmias, and should be reported immediately.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.