Nokea
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
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Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?
- A. Anxiety related to the mastectomy.
- B. Impaired skin integrity related to the mastectomy.
- C. Pain related to surgical incision.
- D. Self-care deficit related to dressing changes.
Correct Answer: C
Rationale: immediately after surgery, the priority is optimizing the client's comfort
A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the client seek medical attention?
- A. SOB and fatigue
- B. restlessness and muscle spasms
- C. dry mouth
- D. diarrhea
Correct Answer: B
Rationale: Muscle spasms and restlessness are side effects of Haldol.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
- A. Avoid smoking near the client
- B. Turn off oxygen during meals
- C. Adjust the liter flow to 10 as needed
- D. Remind the client to keep mouth closed
Correct Answer: A
Rationale: Avoid smoking near the client. Oxygen supports combustion, posing a fire risk if smoking occurs nearby.
A client is seen in the emergency room with complaints of chest pain.
- A. Which assessment finding suggests to the nurse that the client’s chest pain is cardiac in origin?
- B. The client states that the pain is sharp and increased by deep breathing.
- C. The client reports a history of a fatty meal before the pain began.
- D. The client states that the pain is substernal and radiates to the left arm.
- E. The client reports that the pain began when he was lifting a heavy object.
Correct Answer: C
Rationale: Substernal chest pain radiating to the left arm is a classic symptom of cardiac ischemia, such as angina or myocardial infarction. Sharp pain with breathing suggests pleuritic causes, fatty meals indicate gastroinTest inal issues, and pain with lifting suggests musculoskeletal strain.