Nokea
The nurse is caring for a client who is receiving IV fluids at 125 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 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
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A mother calls the clinic, concerned that her 5 week-old infant is 'sleeping more than her brother did.' What is the best initial response?
- A. Do you remember his sleep patterns?'
- B. How old is your other child?'
- C. Why do you think this a concern?'
- D. Does the baby sleep after feeding?'
Correct Answer: C
Rationale: Open ended questions encourage further discussion and conversation, thereby eliciting further information.
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
An adult is admitted with suspected urolithiasis. Which nursing diagnosis is of highest priority when planning nursing care for this client immediately after admission?
- A. Acute pain
- B. Diarrhea
- C. Risk of ineffective health maintenance
- D. Risk of infection
Correct Answer: A
Rationale: Kidney stones cause severe pain, making acute pain the priority diagnosis for immediate relief and comfort. Other diagnoses are secondary.
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
- A. A change in appetite
- B. Respiratory change
- C. Anxiety
- D. Activity intolerance
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
A five-year-old girl after the application of a cast to the left arm.
After the cast is applied, the nurse should
- A. petal the edges of the cast to prevent irritation.
- B. elevate the client's left arm on two pillows.
- C. apply cool, humidified air to dry the cast.
- D. ask the client to move her fingers to maintain mobility.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct-minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast