Nokea
What is the first symptom to occur in hypovolemia?
- A. Hypotension
- B. Thirst
- C. Central venous pressure below 2 to 3 mmHg
- D. Urine specific gravity high
Correct Answer: B
Rationale: Thirst is the earliest indicator of hypovolemia, as the body signals the need for fluid replacement before more severe signs like hypotension develop.
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A 35-year-old female client has returned to her room following surgery on her right femur. She has an IV of D5 1/2 NS infusing at 125 cc/hr, and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. The client last voided 5 1/2 hours ago when she was given her preoperative medication. To monitor and promote the return of urinary function after surgery, the nurse should:
- A. provide food and fluids at the client's request.
- B. maintain the IV, increasing the rate hourly until the client voids.
- C. report to the surgeon if the client is unable to void within 8 hours of surgery.
- D. hold the morphine sulfate injections for pain until the client voids, explaining to the client that morphine sulfate can cause urinary retention.
Correct Answer: C
Rationale: Provision of food and fluids promotes bowel elimination. Postoperative nutritional needs are physician determined, not client determined. Increasing IV fluids postoperatively will not cause a client to void. Any change in the rate of administration of IV fluids is determined by the physician, not the nurse. If the postoperative client with normal kidney function cannot void 8 hours after surgery, the client is retaining urine. The client may need catheterization or medication. The physician will provide orders for either, as necessary. While morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
Mary presents difficulty breathing, fatigue, orthopnea, and palpitation, and is diagnosed as having aortic insufficiency. After undergoing aortic valve repair, what medication would you expect her physician to prescribe?
- A. Ativan.
- B. Haldol.
- C. Heparin.
- D. Thorazine.
Correct Answer: C
Rationale: Anticoagulation is often required post-valve repair to prevent clot formation.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.
Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
Instructions for a patient at risk for testicular cancer include
- A. Restrict potassium, phosphate, sodium, protein in diet.
- B. Self-catheterization of ileal reservoir.
- C. Testicular self-exam.
- D. Change in color of urine is to be expected.
Correct Answer: C
Rationale: Regular self-exams help detect testicular cancer early.