Nokea
A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?
- A. Shivering
- B. Oliguria
- C. Bradypnea
- D. Constricted pupils
Correct Answer: B
Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.
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A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct Answer: D
Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.
A nurse is providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?
- A. This medication can be used to help manage asthma symptoms during an acute asthma attack
- B. This medication should be taken before exercise and physical activity
- C. This medication should be taken regularly as prescribed without discontinuing abruptly
- D. This medication helps decrease swelling and mucus production
Correct Answer: D
Rationale: Montelukast works as a leukotriene receptor antagonist, reducing inflammation and mucus production, which helps prevent asthma attacks but is not used for acute treatment. It is important for the client to understand that montelukast should be taken regularly to manage asthma symptoms and should not be abruptly discontinued. Taking the medication before exercise is not a typical instruction for montelukast.
A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client's oxygen saturation level
- C. Provide standby assistance when getting out of bed
- D. Encourage foods high in potassium
Correct Answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?
- A. Shortness of breath
- B. Petechiae
- C. Change in mental status
- D. Edema
Correct Answer: D
Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.
A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct Answer: D
Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.