Nokea
A nurse is admitting a client who has been admitted with a diagnosis of upper GI bleeding to the hospital. The nurse should assess the client for which of the following? Select all that apply.
- A. Dry, flushed skin.
- B. Decreased urine output.
- C. Tachycardia.
- D. Widening pulse pressure.
- E. Rapid respirations.
- F. Thirst.
Correct Answer: A,B,C,E,F
Rationale: Upper GI bleeding can lead to hypovolemia, causing dry, flushed skin, decreased urine output, tachycardia, rapid respirations, and thirst. Widening pulse pressure is not typically associated with hypovolemia.
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A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:
- A. Position the client on a firm mattress
- B. Keep the involved extremity warm with blankets
- C. Position the left leg at or below the body's horizontal plane
- D. Encourage the client to raise and lower his leg four times every hour
Correct Answer: C
Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.
The nurse using healing touch affects a client's pain primarily through:
- A. Energy fields.
- B. Touch therapy.
- C. Massage.
- D. Hypnosis.
Correct Answer: A
Rationale: Healing touch primarily uses energy fields to promote relaxation and pain relief, distinct from massage, physical touch therapy, or hypnosis.
A 52-year-old client with lung cancer tells the nurse that he has a low-grade fever (100.6°F [38.1°C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the nurse?
- A. Advise the client to take two acetaminophen tablets every 4 to 6 hours for 2 days and call back if his temperature increases to 101°F (38.3°C) or greater.
- B. Advise the client that this is an expected side effect of the radiation therapy and to keep his appointment in 2 weeks.
- C. Advise the client to come to the office to be examined today.
- D. Advise the client to go to the nearest emergency department.
Correct Answer: C
Rationale: Fever, cough, and fatigue post-radiation may indicate infection or pneumonitis, requiring prompt evaluation, especially in a lung cancer patient, so an office visit today is appropriate.
An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?
- A. Empty the catheter drainage bag.
- B. Cover the client with warm blankets.
- C. Hang new bags of irrigation.
- D. Turn the client.
Correct Answer: B
Rationale: Room-temperature irrigation can cause hypothermia, especially in an elderly client. Covering with warm blankets is the most important intervention to maintain normothermia.
Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy?
- A. Glycosuria.
- B. A 1- to 2-pound weight gain.
- C. Decreased appetite.
- D. Elevated temperature.
Correct Answer: D
Rationale: An elevated temperature after the first few days of TPN may indicate a complication like infection, particularly catheter-related. Glycosuria can occur with TPN but is managed, a small weight gain is expected, and decreased appetite is not a direct complication. CN: Pharmacological and parenteral therapies; CL: Analyze