Nokea
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings should the nurse report immediately?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, suggesting inadequate perfusion despite dopamine. Options A, B, and D are expected.
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The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
- A. Absence of bowel sounds.
- B. Temperature of 99.8°F (37.7°C).
- C. Pain at the incision site.
- D. Urine output of 30 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
- A. Send the staff member home.
- B. Assess the staff member's compliance with standard precautions.
- C. Assign the staff member only to clients with chronic diseases.
- D. Re-assign the staff member to clean the supply closet.
Correct Answer: A
Rationale: extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3-7 days
The nurse is caring for a client with a new tracheostomy.
- A. What is the priority nursing intervention for a client with a new tracheostomy?
- B. Suction the tracheostomy every 2 hours.
- C. Change the tracheostomy ties daily.
- D. Monitor the stoma for signs of infection.
- E. Keep the tracheostomy cuff inflated at all times.
Correct Answer: C
Rationale: Monitoring the stoma for signs of infection is the priority to detect complications early, ensuring airway safety. Suctioning is as needed, ties are changed as needed, and continuous cuff inflation risks tracheal damage.
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step