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The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
- A. Blood pressure of 142/92 mmHg
- B. Pulse of 92 beats per minute
- C. Respiratory rate of 24 per minute
- D. Weight gain of 16 oz per week
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.
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A patient with a compound, open fracture of the femur is scheduled for immediate surgery. Which nursing diagnosis would be most appropriate in the immediate postoperative period?
- A. Risk for Falls
- B. Risk for Infection
- C. Impaired Transfer Ability
- D. Risk for Post-Trauma Syndrome
Correct Answer: B
Rationale: Given that the patient has a compound, open fracture of the femur and is undergoing immediate surgery, the most critical nursing diagnosis in the immediate postoperative period would be the risk for infection. Open fractures are particularly susceptible to infection due to the exposure of the fracture site to external contaminants. Postoperative care should prioritize infection prevention measures like sterile dressing changes, administration of prophylactic antibiotics, and close monitoring for signs of infection such as increased pain, redness, swelling, or drainage from the wound. Mitigating the risk of infection is crucial to prevent complications and promote optimal healing of the fracture. While the other diagnoses are relevant, addressing the risk for infection takes precedence in this scenario.
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
- A. P wave smooth and round
- B. Absent U wave
- C. PR interval 0.30 seconds
- D. ST segment isoelectric
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
A patient has been vomiting for 4 hours. Which hormone will increase secretion in response to the physiologic changes caused by the vomiting?
- A. ADH
- B. Renin
- C. Thyroxin
- D. Aldosterone
Correct Answer: D
Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.
A client with sepsis has a temperature of 40°C. Which dysrhythmia is most likely to occur in this client?
- A. Bradydysrhythmia
- B. Tachydysrhythmia
- C. Wolff-Parkinson-White dysrhythmia
- D. Long QT dysrhythmia
Correct Answer: B
Rationale: A client with sepsis and a temperature of 40°C is likely experiencing a systemic inflammatory response, which can lead to a variety of dysrhythmias. In this case, the client is more likely to develop a tachydysrhythmia (fast heart rate) due to the body's response to the infection. Sepsis can result in an increase in heart rate as the body tries to maintain adequate perfusion to vital organs in response to the inflammatory process. Tachydysrhythmias such as supraventricular tachycardia or atrial fibrillation are commonly observed in septic patients with high fevers.
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
- A. Class I
- B. Class II
- C. Class III
- D. Class IV
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.