Nokea
A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?
- A. Call the Rapid Response Team.
- B. Document and continue to monitor.
- C. Notify the primary care provider.
- D. Repeat blood pressure measurement in 15 minutes.
Correct Answer: A
Rationale: The correct answer is A: Call the Rapid Response Team. A significant drop in blood pressure from 142/76 mm Hg to 88/50 mm Hg indicates a potential life-threatening condition like hypovolemic shock. Calling the Rapid Response Team allows for immediate assessment and intervention to stabilize the client. Other choices are incorrect because documenting and monitoring without intervention can lead to deterioration, notifying the primary care provider may cause delays in critical care, and repeating the blood pressure measurement in 15 minutes may worsen the client's condition if urgent intervention is needed.
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The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)?
- A. Anxiety
- B. Fear of pain
- C. The dying process
- D. Anger toward the nurse.
Correct Answer: A
Rationale: The nurse can address anxiety, fear of pain, and the dying process through education, medication, and emotional support, while anger toward the nurse might require conflict resolution strategies.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
- A. Administer oxygen at 2 liters per minute via nasal cannula.
- B. Assess the client's vital signs including oxygen saturation.
- C. Notify the Rapid Response Team immediately.
- D. Place the client in a high Fowler's position.
Correct Answer: D
Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress.
Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.
What is a common cause of sensorineural hearing loss?
- A. Otitis media
- B. Temporal bone fractures
- C. Otitis externa
- D. Vascular conditions
Correct Answer: D
Rationale: Vascular conditions impair blood supply to the cochlea, causing sensorineural hearing loss.
After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?
- A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
- B. Client's HR is 55 beats/min. Nurse withholds pain medication.
- C. Client has reduced breath sounds. Nurse calls the physician immediately.
- D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.
Correct Answer: C
Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment.
Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.
When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. In acute renal failure, impaired kidney function can lead to electrolyte imbalances, especially hyperkalemia which can be life-threatening. Monitoring serum potassium levels is crucial to prevent cardiac complications. Serum sodium (A) may be altered, but potassium is more critical. Serum calcium (C) and chloride (D) levels are important but not as directly impacted in acute renal failure compared to potassium.