Nokea
Which organ lies retroperitoneally?
- A. Kidneys
- B. Testicles
- C. Urinary bladder
- D. Pancreas
Correct Answer: A
Rationale: The correct answer is A: Kidneys. The kidneys are located retroperitoneally, behind the peritoneum, providing structural protection and maintaining a stable position within the abdominal cavity. This location helps protect them from external physical trauma. Choices B, C, and D are incorrect because testicles, urinary bladder, and pancreas are not located retroperitoneally. Testicles are located in the scrotum, the urinary bladder is located in the pelvis, and the pancreas is located in the upper abdomen, not retroperitoneally.
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A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly.
- B. Provide a complex carbohydrate snack.
- C. Administer 50% dextrose intravenously.
- D. Give 15 grams of a fast-acting carbohydrate.
Correct Answer: D
Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.
A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct Answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?
- A. The child looks at the floor when answering the nurse's questions
- B. The mother's version of the injury is different from the child's version
- C. The child has several abrasions on the chest and legs
- D. The mother refuses to answer questions about family history
Correct Answer: B
Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.
A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?
- A. Hemoglobin 9.5 g/dL
- B. Potassium 6.2 mEq/L
- C. Creatinine 3.5 mg/dL
- D. BUN 50 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.
The nurse is monitoring a client who started taking a new medication for rheumatoid arthritis. What is the most important aspect to monitor?
- A. Signs of gastrointestinal bleeding
- B. Liver function tests
- C. Renal function tests
- D. All necessary monitoring based on the medication prescribed
Correct Answer: D
Rationale: When a client starts a new medication for rheumatoid arthritis, it is crucial to monitor all necessary aspects based on the specific medication prescribed. Different medications can have varying side effects and impacts on different organ systems. Monitoring all relevant parameters ensures the early detection of any adverse effects and helps to maintain the client's safety. While monitoring for signs of gastrointestinal bleeding, liver function tests, and renal function tests are all important in certain situations, the priority is to conduct comprehensive monitoring based on the medication's known effects.