Nokea
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
- A. Assess heart sounds.
- B. Obtain an order for blood cultures.
- C. Prepare for a paracentesis.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (D) improves breathing. Heart sounds (A), blood cultures (B), and paracentesis (C) are secondary.
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Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply.
- A. Systolic blood pressure, 145 mm Hg.
- B. Diastolic blood pressure, 87 mm Hg.
- C. High-density lipoprotein (HDL), 30 mg/dL.
- D. Glycosylated hemoglobin (HbA1c), 10.2%.
- E. Triglycerides, 425 mg/dL.
- F. Urine ketones, negative.
Correct Answer: A,C,D,E
Rationale: Systolic hypertension (145 mm Hg), low HDL (30 mg/dL), high HbA1c (10.2%), and elevated triglycerides (425 mg/dL) indicate poor control and cardiovascular risk, requiring reporting. Normal diastolic pressure and negative ketones are not concerning.
A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply.
- A. Images will appear to be one-third larger.
- B. Look through the center of the glasses.
- C. Use handrails when climbing stairs.
- D. Stay out of the sun for 2 weeks.
Correct Answer: A,B,C
Rationale: The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Staying out of the sun is not necessary, but dark glasses may be used to prevent photophobia.
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
- A. With two people at each side using a drawsheet.
- B. With two people, one at each side using a drawsheet, and one person at the head.
- C. With two people using a roller and a drawsheet.
- D. With two people, one at each side using a drawsheet, one person at the head, and one person at the feet.
Correct Answer: B
Rationale: Using a drawsheet with two people (one per side) and one at the head minimizes skin shearing by providing support and controlled movement, suitable for a drowsy elderly client.
If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do with following?
- A. Apply an ice pack to the pubic area.
- B. Massage the abdomen gently.
- C. Ambulate as much as possible.
- D. Sit in a tub of warm water.
Correct Answer: D
Rationale: Sitting in warm water can soothe bladder irritation and relax pelvic muscles, alleviating lower abdominal pain post-cystoscopy.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) supports recovery in viral hepatitis by reducing metabolic demands. Increased fluids (B) are helpful but secondary. High-protein (C) or avoiding carbohydrates (D) is not indicated.