Nokea
The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?
- A. Change the IV tubing each time a new IV solution is hung.
- B. Cleanse the IV site with an alcohol swab using long strokes.
- C. Limit manipulation of the cannula at the IV insertion site.
- D. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Correct Answer: C
Rationale: will prevent dislodgment of needle
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The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
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.
The nurse is caring for clients in the pediatric clinic.
- A. Which finding in a six-month-old infant requires follow-up?
- B. The anterior fontanel is open.
- C. The child is not sitting unsupported.
- D. The child is not pulling to a standing position.
- E. The child is not rolling from abdomen to back.
Correct Answer: C
Rationale: By six months, infants typically pull to a standing position with support. Failure to do so may indicate developmental delay, requiring follow-up. An open anterior fontanel is normal until 18 months, sitting unsupported begins around 7-8 months, and rolling over is expected by 5-6 months.
The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?
- A. Measures the circulatory volume in the coronary arteries.
- B. Indirectly measures the pressure in the ventricles.
- C. Analyzes the adequacy of pulmonary circulation.
- D. Directly measures the adequacy of CO2 exchange.
Correct Answer: B
Rationale: CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle
A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
- A. Determine what other medications the patient is taking.
- B. Perform a neurological assessment.
- C. Administer haloperidol decanoate (Haldol D) IM stat.
- D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane