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A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Hypotension.
- C. Diaphoresis.
- D. Hyperactive bowel sounds.
Correct Answer: C
Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.
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A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct Answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.
A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?
- A. Place the mouthpiece in your mouth and blow out as quickly as you can.
- B. Exhale slowly into the mouthpiece over 5 seconds.
- C. Take a slow deep breath before blowing into the mouthpiece.
- D. Blow into the mouthpiece at a steady rate for 3 seconds.
Correct Answer: A
Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.
A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?
- A. Urine output of 20 mL/hr
- B. Heart rate of 90/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1 kg in 24 hr
Correct Answer: D
Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. Tidaling in the water seal chamber.
- D. Drainage of 75 mL in the first 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.
A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?
- A. Limit your fluid intake to 3 liters per day.
- B. Increase your fluid intake to 5 liters per day.
- C. Avoid drinking more than 1 liter of fluid per day.
- D. You can drink as much fluid as you want during meals.
Correct Answer: C
Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.