Nokea
A client with a twenty-five-year history of alcohol abuse is seen in the outpatient clinic for treatment of chronic cirrhosis.
Which of the following symptoms would suggest to the nurse that the client is in the early stages of hepatic encephalopathy?
- A. The patient's abdomen is distended with a protruding umbilicus.
- B. The patient has difficulty describing what he does at work.
- C. The patient's respirations are 32, and he appears to be drowsy.
- D. The patient's upper extremities are adducted, and his lower extremities are internally rotated.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hepatic encephalopathy. (1) ascites is symptom of cirrhosis (2) correct-impaired thought processes is early symptom (3) hyperventilation and stupor is late symptom (4) decerebrate/decorticate posturing late symptom
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The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, a serious side effect of carvedilol, risking reduced perfusion in heart failure. Options B, C, and D are normal: heart rate 70 bpm, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.