Nokea
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
- A. S3 heart sound.
- B. Thready pulse.
- C. Flattened neck veins.
- D. Hypoventilation.
Correct Answer: A
Rationale: An S3 heart sound indicates volume overload.
You may also like to solve these questions
Which statements are correct for lithium?
- A. Effective for all
- B. Has a delay of 10 to 28 days in achieving therapeutic benefits
- C. Has a narrow range of safety between a therapeutic serum level and toxic levels
- D. May be therapeutic when administered in combination with any other drugs
Correct Answer: C
Rationale: Lithium has a narrow therapeutic window, requiring careful monitoring to prevent toxicity.
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.
What condition can develop if Mr. Taylor’s chest tube is accidentally pulled out?
- A. Tension pneumothorax
- B. Open pneumothorax
- C. Hemopneumothorax
- D. Paradoxic respirations
Correct Answer: B
Rationale: An open pneumothorax occurs when air enters the pleural space through an external opening.
When developing a teaching plan for a patient, what should the nurse recognize?
- A. Frustration will enhance the patient’s desire to learn
- B. Only formal teaching plans have been found to be effective
- C. The patient’s previous educational experiences do not influence his learning
- D. The patient must accept responsibility for compliance with his therapeutic regimen
Correct Answer: D
Rationale: Patient responsibility is essential for adherence to therapeutic regimens.
To offer the most effective program with the best outcomes, the nurses should initially
- A. Search for an article that describes nursing interventions that are effective for smoking cessation
- B. Develop a clinical question that will allow them to compare different cessation methods during the program
- C. Keep comprehensive records that detail each patient’s progress and ultimate outcomes from participation in the program
- D. Use evidence-based clinical practice guidelines developed from reviews of randomized controlled trials of smoking cessation methods
Correct Answer: D
Rationale: Using evidence-based guidelines ensures the program is grounded in proven methodologies, leading to better outcomes.