Nokea
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.
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The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
- A. Which symptoms suggest fluid volume overload in a 63-year-old woman receiving IV fluids post-surgery?
- B. Temperature 101°F (3°C), BP 96/60, pulse 96 and thready.
- C. Cool skin, respiratory crackles, pulse 86 and bounding.
- D. Complaints of a headache, abdominal pain, and lethargy.
- E. Urinary output 700 cc/24h, CVP of 5, and nystagmus.
Correct Answer: B
Rationale: Fluid volume overload is characterized by symptoms such as a bounding pulse, elevated blood pressure, respiratory crackles (due to pulmonary edema), and distended neck veins. Cool skin and respiratory crackles with a bounding pulse are indicative of this condition. The other options suggest dehydration, non-specific symptoms, or normal findings unrelated to fluid overload.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
A diagnosis of pernicious anemia is made by:
- A. Bone marrow aspiration
- B. Quantitative assay
- C. Weber test
- D. Schilling test
Correct Answer: D
Rationale: The Schilling test diagnoses pernicious anemia by assessing vitamin B12 absorption. Bone marrow aspiration, quantitative assays, or the Weber test (hearing) are not specific to this condition.
While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.