Nokea
Your patient's physician told him that he has hemophilia. You are asked to teach the signs and symptoms of this disease. You respond by saying
- A. Clot formation, especially in the veins of the lower extremities.
- B. Low blood counts and fatigue due to lack of adequate red blood cell production.
- C. High blood counts and clot formation under the nails.
- D. Excessive bleeding after minor trauma.
Correct Answer: D
Rationale: Hemophilia is characterized by excessive bleeding due to a deficiency in clotting factors.
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Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
- A. Assess their understanding of what hospice care services are.
- B. Ask them how they will care for the patient without hospice care.
- C. Talk directly to the patient and family to see if she can change their minds.
- D. Accept their decision since they are Hispanic and prefer to care for their own.
Correct Answer: A
Rationale: The nurse should assess their understanding of hospice care services to ensure they are making an informed decision based on accurate information rather than assumptions or cultural biases.
What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.
A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?
- A. Administer IV fluids as prescribed by the physician.
- B. Provide straws and offer fluids between meals.
- C. Develop plan for added fluid intake over 24 hours.
- D. Teach family members to assist client with fluid intake.
Correct Answer: B
Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.
Which client(s) would be best to assign to an experienced nurse in an ambulatory eye surgery center? (Choose all that apply.)
- A. A client who needs post-operative instructions for cataract surgery.
- B. A client who needs an eye-pad and a metal shield applied.
- C. A client who needs home health referral for dressing changes and eye drops.
- D. A client who needs teaching about self-administration of eye drops.
Correct Answer: A
Rationale: Clients requiring complex post-operative instructions, such as those for cataract surgery, benefit most from the expertise of an experienced nurse.
Appropriate treatment for a patient with cellulitis includes
- A. Petrolatum and vitamin A and D ointment.
- B. Antibiotics, such as cephalexin, and over-the-counter analgesics.
- C. Weight-bearing exercises and diuretics, such as furosemide.
- D. Wet to dry dressings and steroids.
Correct Answer: B
Rationale: Antibiotics are the mainstay of treatment for cellulitis.