Nokea
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.
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The nurse is caring for a patient who experienced a thermal injury two weeks ago. The nurse would be MOST concerned if which of the following is observed?
- A. Increased heart rate and elevated blood pressure.
- B. Temperature of 100.6°F (38.1°C) and decreased respiratory rate.
- C. Increased heart rate and decreased respiratory rate.
- D. Increased respiratory rate and decreased blood pressure.
Correct Answer: D
Rationale: may indicate burn wound sepsis, a life-threatening complication of thermal injury
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataractsurgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The nurse is teaching a client with newly diagnosed diabetes mellitus how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia are experienced?
- A. Eat a candy bar.
- B. Drink ½-cup fruit juice followed by a protein snack.
- C. Inject 10 units of Humulin R.
- D. Inject glucagon.
Correct Answer: B
Rationale: will correct hypoglycemia and stabilize blood sugar
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced