Nokea
A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it exiting from her total hip incision. She asks the nurse, 'Is this supposed to be there?' Which of the following represents the nurse's best response?
- A. œThe drainage is blood and fluid that must be drained out for healing.'
- B. œDon't worry about it. I will explain it when you are more awake.'
- C. œThis blood is being kept sterile and will be given back to you.'
- D. œI will give you something to make you sleep so you will not worry.'
Correct Answer: A
Rationale: Explaining that the drain removes blood and fluid for healing reassures the client and accurately describes the purpose of the drain in a total hip incision.
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A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to:
- A. Maintain skin integrity.
- B. Maintain cardiac conduction stability.
- C. Decrease cardiac output.
- D. Increase activity level.
Correct Answer: B
Rationale: Maintaining cardiac conduction stability is the priority post-pacemaker insertion to ensure the device effectively manages bradycardia.
A young adult client has been diagnosed with type 1 diabetes. He has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL. He is also receiving I.V. antibiotics for a urinary tract infection. After 4 hours, the physician orders discontinuation of the insulin drip. The nurse should next?
- A. Discontinue the insulin drip, as ordered.
- B. Hang the next I.V. dose of antibiotic before discontinuing the insulin drip.
- C. Inform the physician that the client has not received any subcutaneous insulin yet.
- D. Add glargine (Lantus) to the insulin drip before discontinuing it.
Correct Answer: C
Rationale: Discontinuing an insulin drip without initiating subcutaneous insulin risks rebound hyperglycemia in type 1 diabetes. The nurse should inform the physician to ensure a subcutaneous insulin order is in place.
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
- A. Begin chest compressions.
- B. Call the rapid response team.
- C. Remove the family from the room.
- D. Ventilate the client with an ambu bag.
Correct Answer: B
Rationale: Unresponsiveness, hypotension, and low SpO2 indicate a critical condition. Calling the rapid response team ensures immediate multidisciplinary intervention.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3ˆ’, 24 mEq/L. Based upon the client's PaO2, which of the following conclusions would be accurate?
- A. The client is severely hypoxic.
- B. The client is low but poses no risk for the client.
- C. The client's PaO2 level is within normal range.
- D. The client requires oxygen therapy with very low oxygen concentrations.
Correct Answer: A
Rationale: A PaO2 of 50 mm Hg indicates severe hypoxia (normal is 75–100 mm Hg), requiring urgent oxygen therapy. It poses significant risk and is not normal or manageable with low concentrations.
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.