Nokea
The nurse is using a hypothermia blanket for the febrile client. Which findings should prompt the nurse to consider that the client is hypothermic? Select all that apply.
- A. Increased urine output
- B. Increased drowsiness
- C. Decreased heart rate (HR)
- D. Decreased blood pressure (BP)
- E. Increased core body temperature
Correct Answer: B,C,D
Rationale: B: Drowsiness results from low cardiac output affecting the CNS. C: Decreased HR reflects thermoregulation effects. D: Decreased BP reduces cardiac workload. A: Hypothermia decreases urine output. E: Hypothermia lowers core temperature.
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The nurse is turning a client who has a new prosthetic hip. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C. flexing the hip at 80° flexion
- D. flexing the hip at 90°
Correct Answer: B
Rationale: New prosthetic hips should have an abduction pillow in place to avoid adduction.
Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
- A. Assess the client for dizziness and feel the temperature of extremities
- B. Obtain a manual BP cuff and machine and retake the client's BP
- C. Elevate the head of the client's bed and assist the client out of bed
- D. Review the medical record and determine the client's normal BP range
Correct Answer: A
Rationale: A: Assessing for hypotension symptoms like dizziness or cold extremities is priority. B: Retaking BP follows assessment. C: Ambulating risks falls with hypotension. D: Reviewing records is secondary.
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
- A. serotonin
- B. cortisone
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.
In teaching clients with Buck's Traction, the major areas of importance should be:
- A. nutrition, ROM exercises.
- B. ROM exercises, transportation.
- C. nutrition, elimination, comfort, safety.
- D. elimination, safety, isotonic exercises.
Correct Answer: C
Rationale: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.
Which of the following is least important to test when assessing the client's motor skills?
- A. strength
- B. knowledge of ergonomics
- C. balance
- D. coordination
Correct Answer: B
Rationale: When assessing a client's motor skills, testing the client's strength, balance and coordination are most important. The client's knowledge of ergonomics is less relevant.