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A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
- A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Administer intravenous fluid bolus as prescribed by the healthcare provider.
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
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While assessing a patient with degenerative joint disease, the nurse notices Heberden's nodes, and large prominences on the patient's fingers that are reddened and painful. What should the nurse do?
- A. Discuss strategies for managing chronic pain with the patient.
- B. Check the patient's radial pulses and capillary refill time.
- C. Immediately notify the healthcare provider of the finding.
- D. Review the patient's dietary intake of high-protein foods.
Correct Answer: A
Rationale: Discussing chronic pain management strategies addresses the discomfort associated with Heberden's nodes, a common osteoarthritis feature.
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema.Concurrent and ascites in clients with cirrhosis?
- A. Decreased renin-angiotensin response related to an increase in renal blood flow.
- B. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
- C. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
- D. Decreased portacaval pressure with greater collateral circulation.
Correct Answer: B
Rationale: Hypoalbuminemia reduces oncotic pressure, causing fluid to leak into tissues and abdomen, leading to edema and ascites.
Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?
- A. Keep the head of the bed elevated until the treatment is completed.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Monitor the client's intravenous site hourly during the treatment.
- D. Administer an antiemetic before starting the chemotherapy.
Correct Answer: C
Rationale: Hourly IV site monitoring allows early detection of extravasation, preventing tissue damage from vesicant chemotherapy.
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is the primary diagnostic procedure for bacterial meningitis, allowing analysis of cerebrospinal fluid for bacterial presence and characteristics.
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
- A. Take prescribed cortisone accurately.
- B. Use a walker when weakness occurs.
- C. Avoid extreme environmental temperatures.
- D. Increase daily intake of sodium in diet.
Correct Answer: A
Rationale: Accurate cortisone administration is vital to manage Addison's disease and prevent adrenal crisis.