Nokea
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.
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The nurse knows that the client understands how to determine when the nitroglycerin tablets need replacing when the client makes which statement?
- A. The tablets will be discovered.
- B. The tablets will be discolored.
- C. They won't tingle in my mouth.
- D. They will disintegrate when I touch them.
Correct Answer: C
Rationale: Fresh nitroglycerin tablets cause a tingling sensation under the tongue; loss of this sensation indicates loss of potency.
Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching?
- A. I must take all the prescribed antibiotics.'
- B. I may get a vaginal yeast infection with penicillin.'
- C. I will have no problems as long as I take my medication.'
- D. My throat culture was positive for a streptococcal infection.'
Correct Answer: C
Rationale: Assuming no problems with medication (C) ignores potential complications like recurrence, indicating a need for teaching. Completing antibiotics (A), yeast infection (B), and strep culture (D) are correct.
When two rescuers perform CPR on an adult, what is the ratio of compressions to ventilations?
- A. 30 compressions to 2 breaths
- B. 10 compressions to 1 breath
- C. 1 compression for each breath
- D. 1 compression to 5 breaths
Correct Answer: A
Rationale: Two-rescuer adult CPR uses a 30:2 ratio to balance circulation and oxygenation.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.