Question 5061)
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid “something bad is about to happen.” How should the nurse position this client?
A. Sitting upright
B. Head lower than feet
C. Supine
D. Prone
Answer: A
Explanation: The client’s symptoms suggest pulmonary edema. Any client with severe dyspnea, orthopnea, and bubbling respirations needs to be in an upright position. An upright position decreases venous return to the heart by allowing blood to pool in the extremities. Decreasing venous return lowers the output of the right ventricle and decreases lung congestion. Sitting upright also allows the abdominal organs to fall away from the diaphragm, easing breathing. Positioned with head lower than feet would not promote venous pooling in the extremities and would increase venous return and pulmonary congestion. The supine position also would contribute to increased pulmonary congestion. The prone position, lying on the abdomen, does not decrease venous return, which is what this client desperately needs.
Question 5062)
An adult male has a high level of high-density lipoproteins (HDL) in proportion to low-density lipoproteins (LDL). How does this relate to his risk of developing coronary artery disease (CAD)?
A. His risk for CAD is low.
B. There is no direct correlation
C. His risk may increase with exercise.
D. His risk will increase with age.
Answer: A
Explanation: Although elevated LDL levels in proportion to HDL levels are positively correlated with CAD, elevated HDL levels in proportion to LDL levels may decrease the risk of developing CAD. HDL levels may increase with exercise, thereby decreasing a client’s risk of CAD. Age is not a predictor of HDL and LDL levels.
Question 5063)
A 72-year-old man had a total hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan’s sign. Which of the following will be included in the initial care of this man?
A. Warm packs to the left leg
B. Vigorous massage of the left leg
C. Placing the left leg in a dependent position
D. Performing range of motion exercises to the left leg
Answer: A
Explanation: Warm, moist heat applied to the extremity reduces the discomfort associated with thrombophlebitis. Vigorous massage of the leg is contraindicated in any client because it may cause a thrombus to become dislodged and possibly cause a pulmonary embolus. The leg should be elevated to prevent venous stasis. Leg exercises are used to prevent thrombophlebitis; once a client has thrombophlebitis, the leg is not exercised to prevent the thrombus from becoming an embolus.
Question 5064)
The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet?
A. Milkshake, hot dog, and beets
B. Beef steak, spinach, and grape juice
C. Chicken salad, green peas, and coffee
D. Macaroni and cheese, coleslaw, and lemonade
Answer: B
Explanation: Beef, spinach, and grape juice contain iron. Milk contains no iron.
Question 5065) Ferrous sulfate is prescribed for a client. She returns to the clinic in two weeks. Which assessment by the nurse indicates that she has NOT been taking iron as ordered?
A. The client’s cheeks are flushed
B. The client reports having more energy.
C. The client complains of nausea
D. The client’s stools are light brown.
Answer: D
Explanation: Iron turns stool black. The other answers all indicate compliance with the medication regimen.
Question 5066)
A Schilling test has been ordered for a client suspected of having pernicious anemia. What is the nurse’s primary responsibility in relation to this test?
A. Collect the blood samples
B. Collect a 24-hour urine sample
C. Assist the client to x-ray
D. Administer an enema
Answer: B
Explanation: The client is given radioactive vitamin B12 orally, and a 24-hour urine sample is collected to see if vitamin B12 is absorbed from the GI tract into the bloodstream and excreted in the urine.
Question 5067)
A client who receives a diagnosis of pernicious anemia asks why she must receive vitamin shots. What is the best answer for the nurse to give?
A. “Shots work faster than pills.”
B. “Your body cannot absorb vitamin B12 from foods.”
C. “Vitamins are necessary to make the blood cells.”
D. “You can get more vitamins in a shot than a pill.”
Answer: B
Explanation: Injections of vitamin B12 will be necessary because without intrinsic factor, her body cannot absorb vitamin B12 from foods.
Question 5068)
A client who has been diagnosed as having pernicious anemia asks how long she will have to take shots. What is the best answer for the nurse to give?
A. “Until your blood count returns to normal.”
B. “Until your blood count returns to normal.”
C. “For the rest of your life.”
D. “That varies with each person. Ask your doctor.”
Answer: C
Explanation: Because she is deficient in intrinsic factor and cannot absorb vitamin B12 from foods, she will have to take vitamin B12 shots for life.
Question 5069)
A toddler has been treated for sickle cell crisis. The crisis subsides, and the child improves. Which statement is essential for the nurse to include in the discharge teaching?
A. Your child will bruise easily. Do not let your child bump into things.
B. Notify the physician immediately if your child develops a fever.
C. Your child will need special help with feeding.
D. Observe your child frequently for difficulty breathing.
Answer: B
Explanation: Fevers cause dehydration and sickling, which may result in a crisis.
Question 5070)
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
A. “We are going to the mountains for our vacation this year.”
B. “It’s a good thing she likes to drink juices.”
C. “If she needs something for pain, I will give her baby acetaminophen.”
D. “I will make sure that she doesn’t get chilled when it is cold outside.”
Answer: A
Explanation: The mountains are high in altitude and have less oxygen saturation, which may precipitate an attack. Drinking juices is good because it will help to prevent dehydration. Acetaminophen is better for the child than aspirin, which may cause acidosis. The child should be protected from extremes in temperature
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