Nokea
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
- A. Lower the head of the bed to semi-Fowler's.
- B. Administer prescribed corticosteroids.
- C. Slow infusion rate and contact the provider.
- D. Change infusion to lactated Ringer's and maintain rate.
Correct Answer: C
Rationale: Correct Answer: C - Slow infusion rate and contact the provider.
Rationale: The client is showing signs of fluid volume overload with dyspnea, elevated blood pressure, and a significant fluid intake-output discrepancy. Slowing the infusion rate will help reduce fluid intake and potentially prevent worsening of the overload. Contacting the provider is crucial for further assessment and possible adjustment of the treatment plan.
Summary:
A: Lowering the head of the bed may help with respiratory distress but does not address the underlying issue of fluid overload.
B: Administering corticosteroids is not indicated for fluid overload and may worsen the situation.
D: Changing to lactated Ringer's does not address the immediate need to slow down the infusion rate and seek provider guidance.
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A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
- A. Altered level of consciousness
- B. Cheyne-Stokes respirations
- C. Decorticate posturing
- D. Pupillary dilation
Correct Answer: A
Rationale: The correct answer is A: Altered level of consciousness. This is the first sign of deteriorating neurological status in a client with increased intracranial pressure. Changes in consciousness indicate impairment in brain function, signaling potential brain injury or worsening condition. Altered level of consciousness can progress rapidly if not addressed promptly.
Choice B, Cheyne-Stokes respirations, is associated with abnormal breathing patterns and typically occurs in conditions like heart failure or brain injury, but it is not the first sign of neurological deterioration.
Choice C, Decorticate posturing, is a sign of brain injury but typically occurs after alterations in consciousness.
Choice D, pupillary dilation, can be a sign of increased intracranial pressure, but it usually occurs after alterations in consciousness.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP. Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?
- A. Blood pressure 90/50 mm Hg
- B. Oxygen saturation 95%
- C. Heart rate 60/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 90/50 mm Hg. Dopamine is a vasopressor used to increase blood pressure in hypovolemic shock. A low blood pressure reading of 90/50 mm Hg indicates inadequate perfusion, warranting an increase in dopamine dosage to improve cardiac output. Oxygen saturation (B) and respiratory rate (D) are not direct indicators for adjusting dopamine dosage. A heart rate of 60/min (C) may be within normal limits depending on the client's condition.
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Consume a diet that is high in calories. Patients with COPD often have increased energy needs due to the increased work of breathing. Providing a high-calorie diet helps maintain energy levels and prevent weight loss. Choice B is incorrect because adequate hydration is crucial to help thin mucus and make it easier to clear from the airways. Choice C is incorrect as strenuous exercise can exacerbate COPD symptoms; moderate exercise is recommended. Choice D is incorrect because carbohydrates are an essential energy source and reducing intake can lead to increased fatigue in COPD patients.
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person, place, and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic, cough is productive, and mucous is yellow in color.
- E. Wheezes and crackles heard upon auscultation.
Correct Answer: D
Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status. Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.