Nokea
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
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Priority Decision: The nurse prepares to interview a patient for a nursing history but finds the patient in obvious pain. Which action by the nurse is the best at this time?
- A. Delay the interview until the patient is free of pain.
- B. Administer pain medication before initiating the interview.
- C. Gather as much information as quickly as possible by using closed questions that require brief answers.
- D. Ask only those questions pertinent to the specific problem and complete the interview when the patient is more comfortable.
Correct Answer: A
Rationale: The correct answer is 'Delay the interview until the patient is free of pain.' Pain can interfere with concentration and communication, making it difficult for the patient to provide accurate information. Delaying the interview ensures better quality data collection once the patient is comfortable.
A 44-year-old female client had an emergency cholecystectomy three days ago for a ruptured gallbladder. The client has severe abdominal pain, abdominal rigidity, distension, increased temperature, tachycardia and an elevated white blood count (WBC). The client has probably developed:
- A. gastritis.
- B. evisceration.
- C. peritonitis.
- D. a pulmonary embolism.
Correct Answer: C
Rationale: Assessment findings of gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity, which causes infection and irritation. Assessment findings of a pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing, often accompanied by blood-tinged sputum.
A student nurse arrives on the unit and asks you what the rationale for treatment of withdrawal is. What is the best response?
- A. To protect the patient while the body removes the drug from the patient's bloodstream.
- B. To protect the patient from relapsing during withdrawal.
- C. To treat the patient's psychological dependency on the substance.
- D. To treat the symptoms of withdrawal while the body removes the substance from the patient's bloodstream.
Correct Answer: D
Rationale: Treating withdrawal symptoms supports physiological stability as the body clears the substance.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.