Nokea
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
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After pituitary surgery, the nurse should assess the client for which of the following?
- A. Urine specific gravity less than 1.010.
- B. Urine output between 1 and 2 L/day.
- C. Blood glucose level higher than 300 mg/dL.
- D. Urine negative for glucose and ketones.
Correct Answer: A
Rationale: Low urine specific gravity (<1.010) may indicate diabetes insipidus, a common complication post-pituitary surgery due to reduced vasopressin.
A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
- A. On the floor with the feet flat.
- B. On a low footstool.
- C. In any comfortable position with legs uncrossed.
- D. On a high footstool so the feet are level with the chair seat.
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client:
- A. You can sit up whenever you want.'
- B. You must lie flat on your back most of the time.'
- C. You can turn your body.'
- D. You must lie on your stomach.'
Correct Answer: B
Rationale: Buck's traction requires lying flat to maintain traction alignment, limiting movement.
What is the priority intervention for a client with a suspected stroke?
- A. Administer aspirin.
- B. Perform a CT scan.
- C. Monitor neurological status.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Monitoring neurological status is the priority to detect changes and guide timely stroke intervention.
The nurse has reinforced education at a conference on intramuscular (IM) injections. Which of the following statements by the participant would indicate a correct understanding of the teaching?
- A. "Aspiration before injection of IM medications is no longer universally recommended."
- B. "The deltoid muscle provides slower absorption rates than gluteal sites."
- C. "To ease a client's anxiety, inform the client that an IM injection will not hurt."
- D. "The dorsogluteal muscle is recommended as a site for IM injections."
Correct Answer: A
Rationale: Aspiration is not universally recommended for IM injections due to lack of evidence supporting its necessity.