Nokea
An adult client is showing signs of developing hypovolemic shock. Which finding is most likely to be present?
- A. Elevated systolic and lowered diastolic blood pressure
- B. Decreased heart rate
- C. Decreased urine output
- D. Decreased respiratory rate
Correct Answer: C
Rationale: Hypovolemic shock reduces circulating volume, decreasing renal perfusion and causing oliguria (decreased urine output). Blood pressure typically narrows, heart rate increases, and respiratory rate rises.
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The client complains of frequent insomnia affecting her ability to rest well. Which of the following factors or lifestyle choices in her assessment history most likely contributes to her inability to sleep?
- A. Having a slight snack at bedtime
- B. Heart disease prevention of one baby aspirin each day
- C. Reading in bed prior to going to sleep
- D. Smoking 1½ packs of filtered cigarettes each day
Correct Answer: D
Rationale: Nicotine in cigarettes is a stimulant, disrupting sleep and likely contributing to insomnia, unlike snacks, aspirin, or reading.
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
- A. Client in a belt restraint in the semi-Fowler position
- B. Client in mitten restraints in the side-lying position
- C. Client in soft wrist restraints in the supine position
- D. Client in vest restraint in the high-Fowler position
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (A), mitten restraints in side-lying (B), and wrist restraints in supine (C) are safer positions, assuming proper application and monitoring.
The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?
- A. Albuterol 2.5 mg via nebulizer every 4 hours
- B. Potassium chloride 20 mEq (20 mmol) IV every 24 hours
- C. Enoxaparin 40 mg subcutaneously every 24 hours
- D. Methylprednisolone sodium succinate 20 mg IV every 6 hours
Correct Answer: B
Rationale: Potassium chloride (B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (A), methylprednisolone (D) treat asthma, and enoxaparin (C) may prevent thrombosis in immobile patients.
The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
- A. instruct the client to breathe into a paper bag
- B. place the client in a high Fowler's position
- C. assist the client with pursed lip breathing
- D. administer oxygen at 6L/minute via nasal cannula
Correct Answer: C
Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
Laboratory results
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female:
12-16 g/dL
(120-160 g/L)
5 g/dL
The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.
- A. Coarse crackles
- B. Dyspnea
- C. Pallor
- D. Respiratory depression
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (B), pallor (C), and tachycardia (E) as compensatory mechanisms. Crackles (A) suggest fluid overload, and respiratory depression (D) is unrelated.