Nokea
A client develops orthopnea, dyspnea, and basilar crackles.
Which of the following nursing actions would be MOST appropriate for this client?
- A. Elevate the legs to promote venous return.
- B. Decrease the IV fluids and notify the physician.
- C. Orient the client to time, place, and situation.
- D. Prevent complications of immobility.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation
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Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: It is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior.
A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm³, RBC 5.1 ml/mm³, and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis?
- A. Risk for activity intolerance related to decrease in red cells.
- B. Risk for infection related to low white cell count.
- C. Risk for anxiety; secondary to hypoparathyroid disease.
- D. Risk for fluid volume deficit due to decreased fluid intake.
Correct Answer: B
Rationale: clients with a low WBC count are susceptible to infection
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload