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Which of the following complications is associated with mechanical ventilation?
- A. Gastrointestinal hemorrhage.
- B. Immunosuppression.
- C. Increased cardiac output.
- D. Pulmonary emboli.
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.
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The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.
A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority.
- A. Administer morphine sulfate 2 mg I.V.
- B. Apply oxygen at 2 L via nasal cannula.
- C. Educate the client in anticipation of a thoracentesis.
- D. Coach the client on deep breathing exercise.
Correct Answer: B,A,C,D
Rationale: Oxygen (B) addresses immediate hypoxia, morphine (A) relieves pain and dyspnea, education for thoracentesis (C) prepares for definitive treatment, and deep breathing (D) supports respiratory function.
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
A car accident involves four vehicles on a remote interstate. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter to the nearest hospital?
- A. 10-year-old with a simple fracture of the femur who is crying and cannot find his parents.
- B. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious.
- C. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing.
- D. 70-year-old man with a severe headache who is conscious.
Correct Answer: B
Rationale: The unconscious woman with signs of shock (cold, clammy skin, tachycardia) is in critical condition and requires immediate transport to stabilize her condition.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid rate
- B. Pedal pulses
- C. Nasal cannula flow rate
- D. Capillary refill
Correct Answer: B
Rationale: A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.