Nokea
The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct Answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
You may also like to solve these questions
An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply)
- A. Check his fingerstick glucose
- B. Assess his skin temperature and moisture
- C. Measure his pulse and BP
- D. All of the Above
Correct Answer: D
Rationale: In this scenario, the patient is a young adult male with type 2 diabetes mellitus admitted for a hernia repair who is experiencing weakness and jitteriness. Checking his fingerstick glucose is crucial to assess his blood sugar levels, which can directly impact his symptoms. Assessing his skin temperature and moisture is important to evaluate his peripheral circulation and hydration status. Measuring his pulse and blood pressure helps in gauging his cardiovascular status. Therefore, all the actions mentioned in choices A, B, and C are appropriate for the nurse to implement in this situation to identify the underlying cause of the patient's symptoms. Choice D, 'All of the Above,' is the correct answer because all these actions are necessary for a comprehensive assessment of the patient's condition. Choices A, B, and C are incorrect individually as they each address different aspects of the patient's condition, and a holistic approach is needed to provide optimal care in this situation.
The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
- A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
- D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct Answer: B
Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.
A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What do these symptoms indicate?
- A. Hypoglycemia
- B. Diabetic ketoacidosis (DKA)
- C. Hyperosmolar hyperglycemic state (HHS)
- D. Insulin shock
Correct Answer: B
Rationale: Polyuria, polydipsia, and polyphagia are classic signs of diabetic ketoacidosis (DKA), which occurs due to a combination of hyperglycemia and ketone production. Hypoglycemia (Choice A) is characterized by low blood sugar levels, leading to symptoms like confusion, shakiness, and sweating, which are different from the symptoms described in the scenario. Hyperosmolar hyperglycemic state (HHS) (Choice C) typically presents with severe hyperglycemia, dehydration, and altered mental status, rather than the triad of symptoms mentioned. Insulin shock (Choice D) refers to a severe hypoglycemic reaction due to excessive insulin, manifesting with confusion, sweating, and rapid heartbeat, not the symptoms seen in the client with diabetes mellitus described in this scenario.
Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?
- A. Encourage the client to use an abductor pillow when ambulating.
- B. Teach the client to perform leg exercises in bed.
- C. Assist the client to sit at the edge of the bed.
- D. Assist the client to turn while an abductor pillow is between the legs.
Correct Answer: D
Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.
A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?
- A. Pain
- B. Nocturia
- C. Dyspnea
- D. Frequent cough
Correct Answer: A
Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.