Nokea
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- 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, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.
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The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
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.