Nokea
The nurse is caring for a client with a diagnosis of postpartum hemorrhage. Which vital sign change is most likely to be observed?
- A. Tachycardia
- B. Hypotension
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Postpartum hemorrhage causes significant blood loss leading to tachycardia (to compensate for reduced volume) and hypotension (from decreased perfusion). Both are common vital sign changes.
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A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:
- A. Glucocorticoid followed by the bronchodilator
- B. Bronchodilator followed by the glucocorticoid
- C. Alternate successive administrations
- D. According to the client's preference
Correct Answer: B
Rationale: The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. Client teaching regarding the use and effects of inhalers will promote client understanding and compliance.
The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:
- A. Position the client flat in bed
- B. Administer eye drops as ordered
- C. Restrict fluids before surgery
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.
A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?
- A. Mild fatigue
- B. Hypotension
- C. Slight headache
- D. Stable weight
Correct Answer: B
Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (A), headache (C), and stable weight (D) are less concerning.
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
- A. She should be able to control evacuation of her bowels.
- B. She should be able to return to a regular diet.
- C. She should be able to resume sexual activity.
- D. She should be able to manage her own care.
Correct Answer: A
Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.
An obstructing stone in the renal pelvis or upper ureter causes:
- A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males
- B. Urinary frequency and dysuria
- C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor
- D. Dull, aching, back pain
Correct Answer: C
Rationale: Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter within the bladder wall. An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.