Nokea
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.
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If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do with following?
- A. Apply an ice pack to the pubic area.
- B. Massage the abdomen gently.
- C. Ambulate as much as possible.
- D. Sit in a tub of warm water.
Correct Answer: D
Rationale: Sitting in warm water can soothe bladder irritation and relax pelvic muscles, alleviating lower abdominal pain post-cystoscopy.
The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin.
- B. Steroids.
- C. Sulfonylureas.
- D. Angiotensin-converting enzyme (ACE) inhibitors.
Correct Answer: B
Rationale: Steroids can increase blood glucose levels, complicating diabetes management by causing hyperglycemia.
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
- A. Help keep him well hydrated.
- B. Dissolve clots that he may have.
- C. Prevent kidney failure.
- D. Treat potential cardiac arrhythmias.
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.
The risk for injury during an attack of Ménière'sdisease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
- A. Place your head between your knees.
- B. Concentrate on rhythmic deep breathing.
- C. Close your eyes tightly.
- D. Assume a reclining or flat position.
Correct Answer: D
Rationale: Assuming a reclining or flat position during a vertigo attack minimizes the risk of falling and injury by stabilizing the client's position.