Nokea
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-gastrectomy due to risk of anastomotic leak, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
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A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems
Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?
- A. Low blood pressure and weight loss.
- B. Thin extremities with easy bruising.
- C. Decreased urinary output and decreased serum potassium.
- D. Tachycardia with complaints of night sweats.
Correct Answer: B
Rationale: clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and requests to be suctioned.
The nurse understands that the client's attention-seeking behaviors may be due to
- A. anger and frustration.
- B. awareness of vulnerability.
- C. increased social isolation.
- D. increased sensory stimulation.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct-is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is MOST appropriate?
- A. Limit exercise to once a week.
- B. Consume a high-sodium diet.
- C. Lose weight if overweight.
- D. Increase alcohol intake.
Correct Answer: C
Rationale: Weight loss reduces blood pressure in hypertensive clients. Options A, B, and D worsen hypertension.