Nokea
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
- A. Assess the 12-lead EKG.
- B. Assess the blood pressure.
- C. Assess the lung sounds.
- D. Assess the urine output.
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.
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A client post-lithotripsy asks about expected symptoms. The nurse should explain:
- A. Bruising at the site.
- B. Severe flank pain.
- C. Clear urine output.
- D. Fever above 102°F.
Correct Answer: A
Rationale: Bruising is common post-lithotripsy due to shock wave impact on tissues.
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas?
- A. Axillae.
- B. Elbows.
- C. Upper arms.
- D. Hands.
Correct Answer: D
Rationale: Weight should be supported on the hands to prevent nerve damage in the axillae.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.