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Liz is an elderly woman brought in by concerned family members. After physical examination, she was diagnosed with dehydration. What assessment findings would you expect to see?
- A. Bradycardia,slowed respirations low body temperature and weight gain.
- B. Rales peripheral edema palpitations and diaphoresis.
- C. Tachypnea tachycardia hypotension poor skin turgor and decreased urinary output.
- D. Malaise lymphadenopathy fever shortness of breath and nausea.
Correct Answer: C
Rationale: The correct answer is Tachypnea, tachycardia, hypotension, poor skin turgor, and decreased urinary output (C). Dehydration leads to reduced blood volume, causing compensatory mechanisms like tachycardia and tachypnea. Poor skin turgor and decreased urinary output are classic signs of fluid loss.
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A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
The physician tells the patient that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. You can help the patient by reinforcing that the primary goal for this type of treatment is:
- A. Cure.
- B. Control.
- C. Palliation.
- D. Permanent remission.
Correct Answer: B
Rationale: The described treatment plan focuses on controlling the disease progression rather than achieving a cure or palliation, given the long-term nature of the intervention.
A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?
- A. Rest in a side-lying position after the tube is removed.
- B. Use the incentive spirometer every 4 hours after the tube is removed.
- C. Avoid speaking for extended periods.
- D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct Answer: C
Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications.
Step-by-step rationale:
1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage.
2. It is essential to allow the airway to recover and prevent irritation or inflammation.
3. Resting the voice can aid in the healing process and reduce the risk of complications.
4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest.
5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications.
6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.
What drugs are used to treat shock in MI, trauma, septicemia, renal failure, and cardiac decompensation?
- A. Dopamine
- B. Digoxin
- C. Epinephrine
- D. Dobutamine
Correct Answer: A
Rationale: Dopamine is a vasopressor that supports blood pressure and improves cardiac output in various types of shock.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
- A. Increase the oxygen flow to 3 L/min.
- B. Assess the client's respiratory status.
- C. Call emergency services for the client.
- D. Have the client cough and expectorate secretions.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. This is the priority because the client is experiencing difficulty breathing, which could indicate a worsening of their condition. By assessing the respiratory status, the nurse can gather vital information to determine the appropriate next steps, such as adjusting the oxygen flow rate, providing respiratory treatments, or seeking further medical intervention. Increasing the oxygen flow without assessing the client's condition could potentially exacerbate the issue. Calling emergency services (choice C) may be necessary based on the assessment findings but should not be the immediate priority. Having the client cough and expectorate secretions (choice D) is important for airway clearance but is not the priority when the client is in distress.