Nokea
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.
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The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
- A. a client with Alzheimer’s requiring assistance with feeding.
- B. a client with osteoporosis complaining of burning on urination.
- C. a client with scleroderma receiving a tube feeding.
- D. a client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: standard, unchanging procedure
Following femoral catheterization for percutaneous coronary intervention (PCI), the client has increasing pain in the catheterization site, and the nurse notes visible edema and induration surrounding the site. The nurse suspects a hematoma and notifies the physician. Which of the following interventions does the nurse anticipate? Select all that apply.
- A. Apply pressure to the site.
- B. Mark margins of edematous, indurated area.
- C. Monitor hemoglobin and hematocrit.
- D. Maintain bedrest.
- E. Administration of clotting factors.
Correct Answer: A,B,C,D
Rationale: Hematoma management includes applying pressure (A), marking edema (B), monitoring hemoglobin/hematocrit (C), and maintaining bedrest (D). Clotting factors (E) are not typically needed.
A client diagnosed with hepatitis B asks the nurse how the virus is transmitted. Which of the following is the correct response?
- A. by infectious blood or needles
- B. by infectious blood, sexual contact, and needles, and from mother to newborn
- C. by contaminated food and water
- D. by contaminated water only
Correct Answer: B
Rationale: Hepatitis B is transmitted via blood, sexual contact, needles, and perinatally from mother to newborn.
The nurse is working with a client who experiences orthostatic hypotension. Which suggestion would benefit the client?
- A. Sleep completely flat and do not use any pillows to prop your head.'
- B. Wear your support stockings when you sleep.'
- C. Take your blood pressure medicine immediately before trying to stand up.'
- D. Do not drink any liquids after 8 p.m.'
- E. None
- F. all the above
Correct Answer: E
Rationale: None of the options directly address orthostatic hypotension effectively. Support stockings during the day (not sleep), slow position changes, and adequate hydration are better strategies.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.