Nokea
A client had a thoracotomy 3 hours ago. For the past 2 hours there has been 100 cc per hour of bloody chest drainage. Which of the following actions should the nurse take FIRST?
- A. Increase the IV fluid rate.
- B. Administer oxygen at 5 L/min per oxygen mask.
- C. Elevate the head of the bed.
- D. Advise the physician of the amount of drainage.
Correct Answer: D
Rationale: Excessive chest drainage (100 cc/hour) suggests hemorrhage, requiring immediate physician notification. Options A, B, and C are secondary interventions.
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The nurse should anticipate the client with a gastric ulcer to have pain
- A. two to three hours after a meal.
- B. at night.
- C. relieved by ingestion of food.
- D. one-half to one hour after a meal.
Correct Answer: D
Rationale: pain related to a gastric ulcer occurs about one-half to one hour after a meal and rarely at night; is not helped by ingestion of food
A 34-year-old male is admitted to the hospital with a possible diagnosis of pheochromocytoma. Which of the following symptoms would the nurse not expect to see during an attack?
- A. Orthostatic hypotension
- B. Diaphoresis
- C. Apprehension
- D. Bradycardia
Correct Answer: D
Rationale: Pheochromocytoma causes catecholamine release, leading to tachycardia, not bradycardia, during an attack.
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 3,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³.
The nurse would expect the patient to exhibit which of the following symptoms?
- A. BP 120/70, pulse 100, respirations 16.
- B. Ankle edema and ascites.
- C. Flushed face and light stools.
- D. Nausea, anorexia, and vomiting.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the situation. (1) correct-increased pulse and respirations are caused by decreased oxygenation of tissues (2) no information to suggest this is provided in the question (3) will be pale due to anemia, normal RBC male 4.3-5.9 million/mm³, female 3.5-5.5 million/mm³, decreased with anemia; normal WBC 4,500-11,000/mm³, decreased (leukopenia) causes susceptibility to infection; normal Hgb - male 13.5-17.5 g/dL, female 12-16 g/dL, decreased with anemia (4) not related to information provided in the question
A Schilling test is ordered for a female client who has pernicious anemia. It is to run from 8:00 A.M. to 8:00 A.M. the following day. How should the nurse plan care for this client?
- A. Leave the urine container with the client at 8:00 A.M. Instruct her to collect all urine until 8:00 A.M. tomorrow. Pick up container at 8:00 A.M.
- B. Have the client empty her bladder at 8:00 A.M., and send this specimen to the lab. Instruct the client to collect all urine until 8:00 A.M. tomorrow.
- C. At 8:00 A.M., ask the client to empty her bladder. Put this specimen in the container and instruct the client to keep all urine until 8:00 A.M. tomorrow. Have her empty her bladder at 8:00 A.M. and discard the specimen.
- D. Have the client empty her bladder at 8:00 A.M. and discard. Instruct the client to collect all urine. At 8:00 A.M. tomorrow, have the client void, and collect this specimen.
Correct Answer: D
Rationale: The Schilling test requires a 24-hour urine collection starting after discarding the first void at 8:00 A.M. and including the final void at 8:00 A.M. the next day to measure B12 absorption accurately.
The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
- A. It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart.'
- B. It is my responsibility to witness the signature of the patient before surgery is performed.'
- C. It is my responsibility to explain the surgery and ask the patient to sign the consent form.'
- D. It is my responsibility to answer questions that the patient may have before surgery.'
Correct Answer: C
Rationale: physician should provide explanation and obtain patient's signature