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A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
- A. A rapid, thready pulse
- B. Decreased peristalsis .
- C. Respiratory congestion
- D. An increased in temperature
Correct Answer: A
Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia.
B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure.
C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern.
D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.
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A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? NursingStoreRN
- A. Patient wanders halls at night.
- B. Patient’s side rails are up with bed alarm activated.
- C. Patient denies pain while ambulating with assistance.
- D. Patient correctly states names of family members in the room.
Correct Answer: D
Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.
Which of the following is an example of a well-stated nursing intervention?
- A. Client will drink 100 mL of water every 2 hours while awake.
- B. Offer client 100 mL of water every 2 hours while awake.
- C. Offer client water when he complains of thirst.
- D. Client will continue to increase oral intake when awake.
Correct Answer: B
Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.
The nurse would evaluate that the patient understands what triggers allergic rhinitis by which of the following patient responses?
- A. “Injected medications.”
- B. “Ingested food and medications.”
- C. “Topical creams and ointments.”
- D. “Airborne pollens and molds.”
Correct Answer: D
Rationale: The correct answer is D because airborne pollens and molds are common triggers for allergic rhinitis. Understanding these triggers helps in avoiding exposure and managing symptoms. Choices A, B, and C are incorrect as they do not specifically relate to allergic rhinitis triggers, focusing instead on other forms of medication or topical applications. By understanding airborne triggers, the patient can take appropriate preventive measures.
Which of the ff. statements, if made by a patient with hypertension, indicates to a nurse a need for more teaching?
- A. “High BP may affect the kidneys and eyes.”
- B. “Most people with hypertension watch their diet.”
- C. “Medication will no longer be needed when I feel better.”
- D. “Many people do not know when their BP is high.”
Correct Answer: C
Rationale: Step-by-step rationale:
1. Statement C indicates a misunderstanding that medication can be stopped when feeling better, which is incorrect.
2. Hypertension is a chronic condition that often requires lifelong medication.
3. This demonstrates a lack of understanding regarding the necessity of long-term management.
4. Statements A, B, and D show knowledge about hypertension's effects, dietary management, and awareness, respectively.
Summary: Statement C is incorrect as it suggests stopping medication, while statements A, B, and D show accurate understanding of hypertension.
Mr. Garcia, a 41-year old chronic alcohol drinker is admitted to the hospital after vomiting bright red blood. He was diagnosed to have a bleeding gastric ulcer and suddenly develops sudden sharp pain in the midepigastric region with a rigid boardlike abdomen. This likely indicates:
- A. development of intestinal
- B. inflammation of the esophagus
- C. perforation of the ulcer
- D. development of additional ulcers
Correct Answer: C
Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.