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Questions 158

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Question 1 of 5

The nurse is preparing to collect a sputum specimen from the client suspected of having tuberculosis. What is the correct method for obtaining a sputum specimen?

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Correct Answer: A, B, C, D

Rationale: Morning collection (
A) yieldsthough sputum is most concentrated. Three consecutive days (
B) ensure reliable tuberculosis diagnosis. Immediate transport (
C) prevents degradation. Mouth care (
D) maintains hygiene. Antiseptic rinse (E) may kill bacteria, invalidating the sample.

Question 2 of 5

A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:

Correct Answer: C

Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.

Question 3 of 5

A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?

Correct Answer: C

Rationale: Rapid weight gain (6 pounds in a week) suggests fluid retention, a sign of glucocorticoid excess, requiring dosage adjustment. Dizziness may indicate underdosing, and the other symptoms are less specific.

Question 4 of 5

The most important reason to closely assess circumferential burns at least every hour is that they may result in:

Correct Answer: D

Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.

Question 5 of 5

A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

Correct Answer: D

Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.

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