Nokea
The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?
- A. Measures the circulatory volume in the coronary arteries.
- B. Indirectly measures the pressure in the ventricles.
- C. Analyzes the adequacy of pulmonary circulation.
- D. Directly measures the adequacy of CO2 exchange.
Correct Answer: B
Rationale: CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle
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The mother of a seven-year-old child is dying.
The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
- A. Death is punishment for his/her actions.
- B. Death is inevitable and irreversible.
- C. Death is temporary and gradual.
- D. Death as a concept based on past experience.
Correct Answer: A
Rationale: Strategy: Remember growth and development. (1) correct-seven-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death
A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
- A. Amount of the drainage.
- B. Character of the drainage.
- C. Consistency of the drainage.
- D. Amount of suction on the drainage system.
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report
The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis?
- A. Loss of acuity in the peripheral visual field.
- B. Increased lacrimation, blurred vision.
- C. Conjunctivitis, dilated pupils bilaterally.
- D. Photophobia, loss of a portion of the visual field.
Correct Answer: D
Rationale: bright flashes of light and client stating that portion of visual field is dark are classic symptoms
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?
- A. Check the ventilator settings every shift.
- B. Suction the endotracheal tube as needed.
- C. Monitor the client’s oxygen saturation.
- D. Ensure the endotracheal tube is secure.
Correct Answer: D
Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention