Nokea
What is the smallest gauge catheter that the nurse can use to administer blood?
- A. 12 gauge
- B. 20 gauge
- C. 22 gauge
- D. 24 gauge
Correct Answer: B
Rationale: An intravenous catheter used to infuse blood should be at least 20 gauge or larger to help prevent additional hemolysis of red blood cells and to allow infusion of the blood without occluding the IV catheter.
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The nurse is ambulating a client for the first time after having abdominal surgery. What clinical manifestations should indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply.
- A. Nausea
- B. Dizziness
- C. Bradycardia
- D. Lightheadedness
- E. Flushing of the face
- F. Reports of seeing spots
Correct Answer: A,B,D,F
Rationale: Orthostatic hypotension occurs when a normotensive person develops symptoms of low blood pressure when rising to an upright position. Whenever the nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension. Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result without intervention, which includes immediately assisting the client to a lying position.
A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
- A. Palpate the pedal pulses.
- B. Measure the abdominal girth.
- C. Assess the client about the level of pain in the area.
- D. Auscultate over the iliac area with a Doppler device.
Correct Answer: B
Rationale: Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected.
A client experiencing difficulty breathing and increased pulmonary congestion was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment value indicates that the therapy has been effective?
- A. The lungs are now clear upon auscultation.
- B. The urine output has increased by 400 mL.
- C. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg.
- D. The serum potassium has decreased from 4.7 mEq to 4.1 mEq (4.7 mmol/L to 4.1 mmol/L).
Correct Answer: A
Rationale: Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.
A client has fallen and sustained a leg injury. Which question should the nurse ask to help determine if the client sustained a fracture?
- A. Is the pain a dull ache?
- B. Is the pain sharp and continuous?
- C. Does the discomfort feel like a cramp?
- D. Does the pain feel like the muscle was stretched?
Correct Answer: B
Rationale: Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching or overextension.
A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury?
- A. Obtaining a chest x-ray
- B. Assessing blood pressure and pulse
- C. Obtaining a complete blood cell count and liver function studies
- D. Scheduling a drug level to be drawn 1 hour after the dose is administered
Correct Answer: B
Rationale: Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.