Nokea
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
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A patient is admitted to the surgical unit with a diagnosis of rule out inTest inal obstruction.
- A. In which position should the nurse place the patient during insertion of a Salem sump NG tube?
- B. Head of bed elevated 30°-45°.
- C. Head of bed elevated 60°-90°.
- D. Side-lying with head elevated 15°.
- E. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Elevating the head of the bed to 60°-90° facilitates swallowing and movement of the NG tube through the gastroinTest inal tract, reducing the risk of aspiration and improving patient comfort during insertion. Other positions do not optimize swallowing or tube passage as effectively.
A client chief complaint in a nursing health history.
Which of the following is an example of a properly recorded client chief complaint in a nursing health history?
- A. Complains of midepigastric discomfort with flatus after meals.'
- B. Area above umbilicus appears to be painful and tender to palpation.'
- C. My stomach hurts after dinner every night.'
- D. Rebound tenderness present in mid-to-upper abdominal area.'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct-chief complaint should be recorded using the client's own words (4) objective finding
A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.