Nokea
The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse's initial action should be to:
- A. Lower the head of the bed
- B. Increase the infusion of normal saline
- C. Administer atropine IV
- D. Obtain a crash cart
Correct Answer: B
Rationale: Increasing normal saline infusion addresses hypovolemic shock, likely due to post-thyroidectomy hemorrhage, as the priority action.
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A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
- A. A weight loss of 2 pounds in 1 day
- B. A serum creatinine 1.25 mg/dL
- C. Urinary output of 50 mL/hr
- D. Rising blood pressure
Correct Answer: D
Rationale: Rising blood pressure is a sign of renal transplant rejection due to impaired kidney function and fluid retention.
The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?
Correct Answer: 31
Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.
The nurse is caring for a client in the clinic who takes captopril and ramipril for hypertension. The health care provider renews the client's prescriptions and leaves the room. Which comment by the client would prompt the nurse to notify the health care provider immediately?
- A. I am able to start walking longer at the gym without getting tired.
- B. Occasionally I am slightly dizzy when standing, so I get up slowly.
- C. I don't get short of breath anymore now that my blood pressure is controlled.
- D. I am going to my gynecologist tomorrow for my 12-week pregnancy checkup.
Correct Answer: D
Rationale: Captopril and ramipril (ACE inhibitors) are contraindicated in pregnancy due to fetal harm, requiring immediate provider notification.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching?
- A. I had my leg removed because of diabetes.
- B. My exercises are going well.
- C. My left leg hurts after I wrap my stump.
- D. I use canes to walk to the bathroom.
Correct Answer: C
Rationale: Pain after wrapping the stump may indicate improper wrapping or complications, requiring further assessment and education.