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The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?
- A. Ensure the IV solution is infusing at the prescribed rate.
- B. Listen to lung sounds.
- C. Notify the healthcare provider of the findings.
- D. Check under the back for evidence of bleeding.
Correct Answer: D
Rationale: Checking for bleeding addresses potential hypovolemic shock, indicated by low blood pressure and tachycardia, prioritizing over IV rate or notification.
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The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
- A. Fatigue.
- B. Pain when eating.
- C. Nausea.
- D. Altered taste sensation.
Correct Answer: B
Rationale: Severe facial pain from trigeminal neuralgia deters eating, leading to imbalanced nutrition.
A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?
- A. I will lift weights every other day.'
- B. I will be able to stand as long as my legs do not hurt.'
- C. I will avoid sitting and crossing my legs.'
- D. I will need to get someone to walk my dog.'
Correct Answer: C
Rationale: Avoiding prolonged sitting and leg crossing improves venous return, aligning with chronic venous insufficiency management.
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
- A. Assess the client's oxygen saturation level.
- B. Determine the client's current glucose level
- C. Give the client one-half cup of fruit juice.
- D. Give the client skim milk and crackers.
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.
A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history indudes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?
- A. Decrease consumption of red meat and most seafood.
- B. Replace dietary table salt with salt substitutes.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Wrap joints with elastic bandage when swollen.
Correct Answer: A
Rationale: Reducing purine-rich foods like red meat and seafood lowers uric acid levels, helping manage gouty arthritis, which likely causes the ankle pain.