The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client?
Correct Answer: 1180
Rationale: Total intake = IV fluids (880 mL D5W + 100 mL NS) + oral fluids (8 oz water + 4 oz milk + 6 oz broth). 1 oz = 30 mL, so oral = (8+4+6) × 30 = 540 mL. Total = 880 + 100 + 540 = 1,180 mL. Output (1,480 mL) is not included in intake.
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The client with aortic stenosis asks why they feel tired. What is the best response?
- A. Your heart is not pumping enough blood.
- B. Your lungs are retaining fluid.
- C. Your blood pressure is too high.
- D. Your heart rate is too slow.
Correct Answer: A
Rationale: Aortic stenosis restricts blood flow from the heart, reducing cardiac output and causing fatigue.
The nurse is monitoring a client with atrial fibrillation. Which finding is most concerning?
- A. Heart rate of 110 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Dizziness and shortness of breath
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Dizziness and shortness of breath suggest hemodynamic instability, which is concerning in atrial fibrillation.
The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client?
- A. Notify the HCP of any redness or irritation of the incision.
- B. Do not lift anything that weighs more than 20 pounds.
- C. Inform the client there may be pain not relieved with pain medication.
- D. Stress the importance of having daily bowel movements.
Correct Answer: A,B
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The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart healthy exercise?
- A. Walk at least 30 minutes a day on flat surfaces.
- B. Perform light weight lifting three (3) times a week.
- C. Recommend high-intensity aerobics daily.
- D. Encourage the client to swim laps once a week.
Correct Answer: A
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