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A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
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A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply.
- A. Begin Warfarin (Coumadin).
- B. Check the postoperative CBC, INR, PTT, & platelet levels.
- C. Confirm availability of blood products.
- D. Monitor the mediastinal chest tube drainage.
- E. Start a Dopamine (Intropin) drip for a systolic BP <100.
Correct Answer: B,C,D
Rationale: Checking lab values (B), confirming blood products (C), and monitoring chest tube drainage (D) address bleeding and ensure timely intervention. Warfarin and dopamine are inappropriate for acute bleeding.
A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:
- A. Within 10 to 15 minutes after the injection.
- B. 1 hour after the injection.
- C. At any time, because timing of meals with lispro injections is unnecessary.
- D. 2 hours before the injection.
Correct Answer: A
Rationale: Insulin lispro is rapid-acting, with onset within 15 minutes. Eating within 10–15 minutes prevents hypoglycemia by matching food intake to insulin action.
Which action is contraindicated for a client with a risk of increased ICP?
- A. Elevate head of bed.
- B. Administer mannitol.
- C. Encourage coughing.
- D. Monitor neurological status.
Correct Answer: C
Rationale: Coughing is contraindicated as it increases intracranial pressure.
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
- A. Maintain circulation
- B. Manage pain
- C. Prepare the client for emergency surgery
- D. Teach postoperative breathing exercises
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:
- A. Above the umbilicus.
- B. At the level of the xiphoid process.
- C. Over the victim's midabdominal area.
- D. Below the xiphoid process and above the umbilicus.
Correct Answer: D
Rationale: The Heimlich maneuver involves thrusts below the xiphoid process and above the umbilicus to safely dislodge a foreign body without injuring internal organs.