Nokea
A nurse is assessing a surgical client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg and on admission to the postsurgical nursing unit, it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. What should the nurse do first?
- A. Notify the surgeon.
- B. Check the client's dressing for bleeding.
- C. Administer oxygen.
- D. Increase the I.V. fluid rate.
Correct Answer: B
Rationale: A drop to 90/70 mm Hg suggests hypovolemia, likely from bleeding. Checking the dressing for bleeding is the first step to identify the cause before further interventions.
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Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
- A. Maintain a fluid intake of 800 mL every 24 hours.
- B. Experience chills only once a day.
- C. Cough productively without chest discomfort.
- D. Experience less nasal obstruction and discharge.
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
- A. Assess the temperature in the affected area
- B. Monitor the radial pulse in the affected arm
- C. Protect the extremity from cold
- D. Avoid using the arm for a venipuncture
Correct Answer: D
Rationale: Avoiding venipuncture in the affected arm is critical preoperatively to preserve vascular integrity and prevent complications (e.g., hematoma) that could affect the axillary-to-axillary bypass surgery. Monitoring pulses, assessing temperature, and protecting from cold are important but less urgent than preventing vascular trauma.
Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
Which stone type is associated with acidic urine?
- A. Calcium oxalate.
- B. Uric acid.
- C. Struvite.
- D. Cystine.
Correct Answer: B
Rationale: Uric acid stones form in acidic urine, requiring alkalinization.
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most like to a predisposing factor for the diagnosis of pneumonia?
- A. Age.
- B. Osteoarthritis.
- C. Vegetarian diet.
- D. Daily bathing.
Correct Answer: A
Rationale: Advanced age weakens the immune system and respiratory muscles, increasing pneumonia risk. Osteoarthritis, a vegetarian diet, and daily bathing do not directly predispose to pneumonia.