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The family of a 48-year-old woman who has multiple sclerosis and spends most of her time in bed or in a chair asks the nurse why they have been told they should have her take deep breaths and cough frequently. What should the nurse include in the reply?
- A. Deep breathing and coughing will help her to move her secretions so she will not develop pneumonia.
- B. Deep breathing and coughing help to prevent clots from developing in the lung.
- C. When she coughs, she increases the amount of oxygen going to the brain, preventing confusion.
- D. Deep breathing increases blood flow to the brain and helps to keep her from getting depressed.
Correct Answer: A
Rationale: Immobility in multiple sclerosis increases pneumonia risk; deep breathing and coughing mobilize secretions, preventing respiratory infections.
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The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
- A. Blood transfusion
- B. Hemodialysis
- C. Renal biopsy
- D. Brain scan
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.
A client receiving oxygen at 6 L/min.
What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
- A. The patient's position in bed and the respiratory rate.
- B. The site used to obtain the blood specimen.
- C. The use of supplemental oxygen.
- D. The patient's diagnosis and blood type.
Correct Answer: C
Rationale: Strategy: Think about each answer choice and how it relates to blood gases. (1) unnecessary to document positioning (2) unnecessary to document site used (3) correct-necessary for accurate Test results (4) unnecessary to document blood type, should document diagnosis
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.