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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Internal bleeding.
- B. Right-sided heart failure.
- C. Cardiac tamponade.
- D. Left ventricular dysfunction.
Correct Answer: B
Rationale: Right-sided heart failure can cause systemic venous congestion, leading to pitting edema and jugular venous distention due to increased central venous pressure.
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The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Restrict protein intake by limiting meats and other high protein foods.
- B. Increase intake of high fiber foods, such as bran cereal.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of potassium rich foods such as bananas or cantaloupe.
Correct Answer: A
Rationale: Restricting protein intake is often recommended for glomerulonephritis to reduce kidney workload and decrease proteinuria, slowing kidney damage progression.
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Sip fluids with each meal.
- B. Chew slowly and thoroughly.
- C. Reduce intake of fatty foods.
- D. Eat small frequent meals.
Correct Answer: D
Rationale: Eating small frequent meals is crucial after gastric bypass surgery to prevent complications like dumping syndrome and manage portion sizes effectively.
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3, which intervention should the nurse include in the plan of care?
- A. Ensure a large gauge IV catheter is used to obtain blood samples.
- B. Wrap bruised areas with elastic bandage dressings.
- C. Remove cold and frozen foods from dietary trays.
- D. Monitor urine and stool for occult blood regularly.
Correct Answer: D
Rationale: Monitoring urine and stool for occult blood is crucial for thrombocytopenic patients at increased risk of bleeding, allowing early detection and management.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Discontinue infusing solution.
- B. Irrigate the catheter manually.
- C. Monitor catheter drainage.
- D. Decrease the flow rate.
Correct Answer: C
Rationale: Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation, ensuring adequate drainage.