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A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
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A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
- A. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath.
- B. Inform the client that she will feel better after receiving a bath and clean sheets.
- C. Obtain the pain medication and delay the bath and position change until the medication reaches its peak.
- D. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.
Correct Answer: C
Rationale: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis?
- A. A 29-year-old Caucasian male
- B. A 19-year-old male of African descent
- C. A 24-year-old Native American/First Nations female
- D. A 36-year-old Eastern European female
Correct Answer: B
Rationale: Sickle cell disease is a common genetic disorder found primarily in clients of African descent but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian male, Native American/First Nations female, or eastern European female will be affected by this disease.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
- A. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.
- B. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.
- C. This type of exercise increases arterial circulation as it returns to the heart.
- D. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Correct Answer: D
Rationale: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.
The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, 'Why do I have to drink so much?' What is the best response by the nurse?
- A. We don't want you to get dehydrated.
- B. It helps adequately hydrate you and ensures a sufficient urine production.
- C. It will help your heart beat regularly and effectively.
- D. It will help restrict blood circulation.
Correct Answer: B
Rationale: The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action?
- A. Evaluate the client's dietary intake.
- B. Observe the client's stools for blood.
- C. Monitor the client's body temperature.
- D. Monitor the client's blood pressure (BP).
Correct Answer: B
Rationale: If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.