Nokea
What is the term used for assessment data that the patient tells you about?
- A. Focused
- B. Objective
- C. Subjective
- D. Comprehensive
Correct Answer: C
Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.
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A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
A client is scheduled for a cholecystectomy in the morning. In planning the postoperative care, the priority nursing diagnosis for the client will be at high-risk for:
- A. knowledge deficit.
- B. urinary retention.
- C. impaired physical mobility.
- D. ineffective breathing pattern.
Correct Answer: D
Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
What correctly describes pursed-lip breathing?
- A. Breathe in to count of 4 and out to count of 2, pursing lips
- B. Breathe in through nose and slowly exhale through pursed lips
- C. Place one hand on abdomen and other on chest, inhaling through pursed lips and exerting pressure on inspiration
- D. Take in a deep breath, through pursed lips, then let out one-third; continue this pattern
Correct Answer: B
Rationale: Pursed-lip breathing involves slow exhalation to prolong expiration and improve airflow.
Which factors place a client at risk for serotonin syndrome?
- A. Coprescription of antidepressants from different classes such as MAOIs and SSRIs
- B. Abnormal levels of cortisol in the body
- C. Adequate time between weaning from one antidepressant drug to initiating another
- D. Premenstrual syndrome
Correct Answer: A
Rationale: Combining certain classes of antidepressants increases serotonin levels excessively, leading to serotonin syndrome.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.