Nokea
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?
- A. Drowsiness
- B. Complaint of nausea
- C. Pulse rate of 82
- D. Restlessness
Correct Answer: D
Rationale: Restlessness. Restlessness, increased heart and respiratory rates, and noisy expiration suggest hypoxia and are indications for suctioning.
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A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: Potassium. If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.
The client is placed on contact precautions. When should the nurse caring for the client plan to put on disposable examination gloves?
- A. As soon as the nurse enters the client's room
- B. Only if anticipating contact with the client's wound
- C. Only if anticipating contact with blood or body fluids
- D. Only if providing care within 3 feet of the client
Correct Answer: A
Rationale: A: Contact precautions require gloves upon entering the room to prevent transmission of infectious organisms, regardless of anticipated contact.
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect
- B. Most antipsychotic drugs cause elevated blood pressure
- C. This provides information on the amount of sodium allowed in the diet
- D. It will indicate the need to institute antiparkinsonian drugs
Correct Answer: A
Rationale: Orthostatic hypotension is a common side effect. Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.
Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours since the preparation and the test is tiring
- C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure the urine output for the next day and immediately notify the health care provider if it should decrease
Correct Answer: D
Rationale: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.
Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.