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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of pericarditis. Which assessment finding is most characteristic?

Correct Answer: A

Rationale: Pericarditis causes chest pain that is typically relieved by sitting forward, reducing pressure on the inflamed pericardium. Bradycardia, edema, and muffled sounds are less specific or indicate complications like tamponade.

Question 2 of 5

The nurse is preparing to administer a dose of vancomycin (Vancocin) IV. Which assessment is most important before administration?

Correct Answer: B

Rationale: Vancomycin is nephrotoxic, so renal function tests (e.g., creatinine) are critical before administration to prevent kidney damage. Liver tests, WBC, and platelets are less directly related.

Question 3 of 5

The nurse is caring for a client with cancer of the pancreas. Which finding indicates involvement of the bile ducts?

Correct Answer: A

Rationale: Pancreatic cancer can obstruct bile ducts causing bilirubin buildup and dark urine (bilirubinuria). Petechiae indicate bleeding dark stools suggest GI bleeding and steatorrhea reflects fat malabsorption not bile duct involvement.

Question 4 of 5

A client with a history of a colostomy is being discharged. The nurse should teach the client to:

Correct Answer: B

Rationale: High-fiber foods can cause blockages or excessive output in a colostomy. Bag changes depend on output, alcohol irritates the stoma, and irrigation is not always required.

Question 5 of 5

The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:

Correct Answer: A

Rationale: Endemic goiter results from iodine deficiency, often in areas with iodine-depleted soil, leading to insufficient thyroid hormone production.

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