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While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Perform a bedside pregnancy test.
- B. Continue with surgery as scheduled.
- C. Calculate gestation from last menstrual cycle.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: A
Rationale: Performing a bedside pregnancy test is critical to confirm or rule out pregnancy, as surgery could pose risks to the fetus, informing the surgical team's approach.
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An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?
- A. Jogging or running are excellent aerobic exercises.
- B. Tennis or racquetball will increase your muscle strength.
- C. Limit your exercise to just your daily activities.
- D. Swimming is an excellent exercise for you.
Correct Answer: D
Rationale: Swimming is a low-impact aerobic exercise that strengthens muscles, improves cardiovascular fitness, and enhances joint flexibility without putting stress on joints, making it ideal for osteoarthritis.
A patient experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?
- A. Headache rated at 0 on 0 to 10 scale.
- B. Oxygen saturation level of 99%.
- C. Ambulates easily without vertigo.
- D. Blood pressure of 120/80 mm Hg.
Correct Answer: C
Rationale: Ambulating easily without vertigo indicates the antihistamine is effective, as it reduces fluid buildup in the inner ear, relieving vertigo, a common symptom of Ménière's disease.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing the radiation site with antibacterial soap and water can cause dryness, inflammation, and infection, indicating a need for further teaching on using mild soap or saline.
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)
- A. Abdominal obesity.
- B. Blood pressure of 150/96 mm Hg.
- C. Elevated high density lipoproteins.
- D. Increased triglyceride levels.
- E. Hyperglycemia.
- F. Hypothyroidism.
Correct Answer: A,B,D,E
Rationale: Abdominal obesity, elevated blood pressure, increased triglyceride levels, and hyperglycemia are components of metabolic syndrome that increase the risk of diabetes and vascular disease, requiring intervention.
The nurse is preparing an older client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed?
- A. Fasting blood sugar of 200 mg/dL (11.1 mmol/L).
- B. Glycosylated hemoglobin A1c of 8%.
- C. Blood urea nitrogen of 22 mg/dL (7.9 mmol/L).
- D. Serum creatinine of 1.9 mg/dL (169 umol/L).
Correct Answer: D
Rationale: Serum creatinine of 1.9 mg/dL (169 umol/L) indicates moderate renal insufficiency, which can increase the risk of contrast-induced nephropathy, a sudden deterioration of kidney function after exposure to contrast media used for imaging studies such as MRI. This should be reported to the healthcare provider to assess the risk and benefit of the procedure and to take preventive measures such as hydration or alternative imaging modalities.