Saturday, 4 July 2020

Q. A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about blood glucose testing. After the session, the client states, "I can't be expected to remember all this stuff." The nurse should recognize this response as most likely related to which of the following?

A. Moderate to severe anxiety.
B. Disinterest in the illness.
C. Early-onset dementia.
D. Normal reaction to learning a new skill.

Correct Answer: A

Reason: Anxiety, especially at higher levels, interferes with learning and memory retention. After the client's anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring. Because the client's illness is a chronic, lifelong illness that severely changes his lifestyle, it is unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would be the cause of the client's frustration and lack of memory. The client's response indicates anxiety. Client responses that would indicate lessening anxiety would be questions to the nurse or requests to repeat part of the instruction.

Friday, 3 July 2020

Q. A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:

A. Administer acetaminophen.
B. Take the client's blood pressure.
C. Discontinue the transfusion.
D. Check the infusion rate of the blood.

Correct Answer: C

Reason: Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction and the nurse's first action should be to discontinue the transfusion as soon as possible and then notify the physician. Antipyretics and antihistamines may be ordered. The nurse would not administer acetaminophen without an order from the physician. The client's blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate.

Thursday, 2 July 2020

Q. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:

A. erythema.
B. leukocytosis.
C. pressurelike pain.
D. swelling.

Correct Answer: C

Reason: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.

Wednesday, 1 July 2020

Q. A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?

A. Autonomy
B. Fidelity
C. Nonmaleficence
D. Veracity

Correct Answer: A

Reason: Autonomy refers to an individual's right to make his own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.

Tuesday, 30 June 2020

Q. A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with:

A. Denial as a primary coping mechanism.
B. Support systems and coping strategies.
C. Decision-making abilities.
D. Transportation and money for the boys.

Correct Answer: B

Reason: The client's resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client's use of denial, decision-making abilities, and ability to pay for transportation; however, the client's support systems will be of more importance in this situation.

Monday, 29 June 2020

Q. A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?

A. Nausea and vomiting
B. Pupillary changes
C. Confusion and restlessness
D. Hypertension

Correct Answer: C

Reason: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine (Mexitil) or tocainide (Tonocard) — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.

Saturday, 27 June 2020

Q. A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following?

A. Perineal lacerations.
B. Retained placental fragments.
C. Cervical lacerations.
D. Urine retention.

Correct Answer: B

Reason: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever the placenta is manually removed after delivery, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urine retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.

Friday, 26 June 2020

Q. Which finding indicates placental detachment?

A. An abrupt lengthening of the cord
B. A decrease in the number of contractions
C. Relaxation of the uterus
D. Decreased vaginal bleeding

Correct Answer: A

Reason: An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus isn't an indication for detachment of the placenta. 



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