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The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 150 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Chest tube drainage of 150 mL/hour is excessive post-CABG, suggesting hemorrhage, requiring immediate evaluation. Options A, B, and D are less concerning: heart rate 100 bpm and temperature 100.8°F are common, and blood pressure 130/80 mmHg is normal.
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A client with end-stage renal failure is to receive a kidney transplant from her sister. Prior to surgery, the client will be scheduled for:
- A. An intravenous pyelogram
- B. Hemodialysis
- C. A voiding cystogram
- D. A renal biopsy
Correct Answer: B
Rationale: Hemodialysis is typically performed before a kidney transplant to optimize the client's electrolyte and fluid balance, ensuring a stable condition for surgery.
A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis. This refers to involuntary muscle spasm of the eye, a known side effect of haloperidol.
The nurse is providing home care to an 89-year-old man. Which comments by the client indicate a need for further follow up? Select all that apply.
- A. Excuse me if my socks don't match. I can't tell blue from green anymore.
- B. Please don't open the blinds. It hurts my eyes when the sun is bright.
- C. Let me get my reading glasses so I can read that pamphlet.
- D. I don't hear so well, but I don't want a hearing aid. I'm too old to spend that kind of money on myself.
- E. Sometimes I have to check the calendar to be sure what day it is.
- F. My grandchildren call me 'old slowpoke' because I walk slower than they do.
Correct Answer: A,B,D,E
Rationale: Color vision loss, photophobia, hearing loss, and memory issues suggest potential medical issues (e.g., cataracts, glaucoma, hearing impairment, cognitive decline) requiring follow-up.
The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.