Nokea
A nurse is caring for a client who is receiving IV fluids. Which of the following findings indicates the client is experiencing fluid overload?
- A. The client's blood pressure is 110/70 mm Hg.
- B. The client's respiratory rate is 24 breaths/min.
- C. The client reports feeling thirsty.
- D. The client's neck veins are distended.
Correct Answer: D
Rationale: Distended neck veins indicate fluid overload, reflecting increased venous pressure. Normal BP, mild tachypnea, or thirst don't specifically signal overload.
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A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect immediate mood improvement.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a side effect to monitor. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.
- A. Tingling of the scalp
- B. Voice alteration
- C. Neck pain
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect of ECT, often resolving post-treatment. Tingling, voice changes, or neck pain are not typically associated with ECT.
A nurse is caring for a client who has a new prescription for digoxin. Which of the following actions should the nurse take?
- A. Check the client's potassium level.
- B. Administer the medication with a high-fiber meal.
- C. Instruct the client to take the medication at bedtime.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: Digoxin toxicity risks increase with hypokalemia, so potassium monitoring is essential. Fiber meals, bedtime dosing, or routine blood pressure checks aren't specific.
A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following actions should the nurse take?
- A. Encourage the client to cough and deep breathe every 2 hr.
- B. Instruct the client to avoid using their arms for support.
- C. Apply a warm compress to the chest incision.
- D. Allow the client to resume a high-sodium diet.
Correct Answer: A
Rationale: Coughing and deep breathing prevent atelectasis and pneumonia. Arm use is encouraged with guidance, warm compresses risk infection, and sodium is restricted.