Nokea
The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to
- A. maintain adequate hydration
- B. assist client to turn, deep breathe, and cough
- C. ambulate client within 12 hours
- D. splint incision
Correct Answer: B
Rationale: assist client to turn, deep breathe, and cough. Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
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The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.
The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions?
- A. "You should don gloves as soon as you enter the client's room."
- B. "Minimize the amount of time the client spends outside the room."
- C. "The client needs to be moved to a private room with negative air pressure."
- D. "Everyone entering the client's room should be sure to put on a mask."
Correct Answer: B
Rationale: B: Minimizing time outside the room reduces pathogen exposure. A, D: Gloves and masks are not required unless infection is present. C: Positive, not negative, air pressure is needed.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicators of fluid balance.
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine. Protamine binds heparin, making it ineffective.