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Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following?
- A. Decreased renal function.
- B. Inadequate pain relief.
- C. Extension of the obstruction.
- D. Inadequate fluid replacement.
Correct Answer: D
Rationale: The low urine output (35 mL in 2 hours) and a 24-hour output (1,200 mL) less than intake (2,000 mL) suggest inadequate fluid replacement, as the body is retaining fluid or losing it through vomiting and NG drainage. Decreased renal function, pain, or obstruction extension are less directly indicated. CN: Physiological adaptation; CL: Analyze
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The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.
What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
- A. Ineffective coping related to the diagnosis of cancer.
- B. Insomnia related to fear of the unknown.
- C. Grieving related to the diagnosis of cancer.
- D. Anxiety related to the need for gastric surgery.
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
- A. Monitor daily weights and urine output.
- B. Permit unrestricted visitation by family and friends.
- C. Provide client education on medications and diet.
- D. Reduce pain and myocardial oxygen demand.
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide which of the following?
- A. Doses of analgesic when pain is a '5' on a scale of 1-10.
- B. Enough analgesia to keep the client semisomnolent.
- C. An analgesia-free period so that the client can carry out daily hygienic activities.
- D. Around-the-clock routine administration of analgesics for continuous pain relief.
Correct Answer: D
Rationale: Around-the-clock administration of analgesics ensures continuous pain relief, which is critical for hospice patients with persistent pain, preventing pain escalation.