Nokea
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
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Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?
- A. Surgical consent form is not signed.
- B. Client's pulse oximeter reading is 96%.
- C. Preoperative chest x-ray report is not available.
- D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, risking cardiac arrhythmias during surgery, requiring immediate correction.
A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.
The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
Choices
A. Request prescription for external catheter device
B. Request prescription for straight catheter
C. Insert indwelling urinary catheter
D. Assist client to bathroom for voiding
E. Increase the IV fluid rate
- B. Potential Condition
Choices
A. Urinary Retention
B. Urinary tract obstruction
C. Overflow Urinary Incontinence
D. IV fluid intake
E. Frequency of voiding
- C. Parameters to monitor
Choices
A. Amount of urine output
B. Residual urine
C. Pain medication effects
D. IV fluid intake
E. Frequency of voiding
Correct Answer: A
Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.
The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?
- A. Ensure the IV solution is infusing at the prescribed rate.
- B. Listen to lung sounds.
- C. Notify the healthcare provider of the findings.
- D. Check under the back for evidence of bleeding.
Correct Answer: D
Rationale: Checking for bleeding addresses potential hypovolemic shock, indicated by low blood pressure and tachycardia, prioritizing over IV rate or notification.