Nokea
The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?
- A. Change in the character of respirations.
- B. Fluctuation in the blood pressure.
- C. Reduction in tissue turgor.
- D. Increase in body temperature.
Correct Answer: A
Rationale: will see dyspnea, cough, edema, hemoptysis
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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 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
- A. clamp off the lumen and label it as 'clotted off.'
- B. gradually increase the pressure on the irrigating solution.
- C. aspirate blood from the lumen to restore patency.
- D. secure the lumen with a Luer-Lock cap and notify the physician.
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
- A. Administer the medication as ordered.
- B. Hold the medication and notify the physician.
- C. Administer half the prescribed dose.
- D. Recheck the pulse in 30 minutes and then administer the medication.
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.