Nokea
Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?
- A. Surgical consent form is not signed.
- B. Client's pulse oximeter reading is 96%.
- C. Preoperative chest x-ray report is not available.
- D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, risking cardiac arrhythmias during surgery, requiring immediate correction.
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A client admitted with thyrotoxicosis is reporting a 'pounding heart in the chest.' Which assessment finding warrants immediate intervention by the nurse?
- A. Anxiety
- B. Hyperglycemia
- C. Fever
- D. Dyspnea.
Correct Answer: D
Rationale: Dyspnea may indicate severe complications like heart failure or thyroid storm, requiring immediate intervention due to potential life-threatening respiratory distress.
Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?
- A. An adolescent who drinks a minimum of four diet drinks daily.
- B. A client who is too busy at work to void when the urge occurs.
- C. A multipara who had pyelonephritis during her last pregnancy.
- D. An older adult who is usually incontinent of urine during the night
Correct Answer: C
Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.