Nokea
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.
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An adult who has a hiatal hernia is seen in clinic. The nurse is reviewing her care with her. Which comment by the client indicates a need for more teaching about managing her condition?
- A. I sit up for an hour after eating.
- B. I miss drinking soda, but I know it is not good for me.
- C. I like to go swimming every day.
- D. I drink hot chocolate instead of coffee.
Correct Answer: D
Rationale: Hot chocolate contains caffeine, which can relax the lower esophageal sphincter, worsening hiatal hernia symptoms. Sitting up, avoiding soda, and swimming are appropriate for management.
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.
A 21-year-old primipara in active labor.
The nurse observes a new graduate nurse palpating the uterine contractions of a 21-year-old primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is MOST appropriate?
- A. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
- B. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
- C. The graduate nurse places one hand on the abdomen over the fundus and with the fingertips, presses gently.
- D. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
Correct Answer: C
Rationale: Strategy: 'MOST appropriate' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) palpations should be done with fingertips, not palms of hands (2) palpations should be done with fingertips, not heels of hands (3) correct-done with fingertips (4) palpations should be done with fingertips, not palms of hands