A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should
... [Show More] the nurse identify as an indication that the treatment was successful?
Increase in hematocrit
increase in respiratory rate
Decrease in heart rate
Decrease in capillary refill time - ANSWERSCorrect Answer:
Decrease in heart rate
Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.
Incorrect Answers:
Increase in hematocrit:
Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease.
increase in respiratory rate
Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range.
Decrease in capillary refill time
Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?
"The transfer of your family member is being done because the provider knows what's best."
"Would you like it if we discussed the transfer with your family member?"
"Why are you so concerned about this transfer?"
"I know how you feel. My parent had to be transferred to a long-term care facility." - ANSWERSCorrect Answer:
"Would you like it if we discussed the transfer with your family member?"
This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality.
Incorrect Answers:
"The transfer of your family member is being done because the provider knows what's best."
This is a defensive response which can hinder further communication.
"Why are you so concerned about this transfer?"
Asking a why question can make the recipient defensive which can hinder further communication.
"I know how you feel. My parent had to be transferred to a long-term care facility."
This is a sympathetic response, which can interfere with a therapeutic relationship.
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?
BUN 21 mg/dL (10 to 20 mg/dL)
Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)
Sodium 132 mEq/L (136 to 145 mEq/L)
Potassium 5.8 mEq/L (3.5 to 5 mEq/L) - ANSWERSCorrect Answer:
Potassium 5.8 mEq/L (3.5 to 5 mEq/L)
When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias.
Incorrect answers:
BUN 21 mg/dL (10 to 20 mg/dL)
This BUN level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider.
Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)
This creatinine level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a a priority for the nurse to report to the provider.
Sodium 132 mEq/L (136 to 145 mEq/L)
This sodium level is slightly below the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider.
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?
"Drink a cup of hot cocoa before bedtime."
"Maintain a consistent time to wake up each day."
"Exercise 1 hour before going to bed."
"Watch a television program in bed before going to sleep." - ANSWERSCorrect Answer:
"Maintain a consistent time to wake up each day."
The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.
Incorrect Answers:
"Drink a cup of hot cocoa before bedtime."
Cocoa contains caffeine, which is a stimulant that can interfere with sleep.
"Exercise 1 hour before going to bed."
Exercising within 2 hr of bedtime can interfere with sleep.
"Watch a television program in bed before going to sleep."
The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of following actions should the nurse take?
Pad the client's wrist before applying the restraints.
Evaluate the client's circulation every 8 hr after application.
Remove the restraints every 4 hr to evaluate the client's status.
Secure the restraint ties to the bed's side rails. - ANSWERSCorrect Answer:
Pad the client's wrist before applying the restraints.
The use of restraints without padding can abrade the client's skin, resulting in client injury.
Incorrect Answers:
Evaluate the client's circulation every 8 hr after application.
The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints.
Remove the restraints every 4 hr to evaluate the client's status.
The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting.
Secure the restraint ties to the bed's side rails.
The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.
A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
Activate the emergency fire alarm.
Extinguish the fire.
Evacuate the client.
Confine the fire. - ANSWERSCorrect Answer:
Evacuate the client.
According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.
Incorrect Answers:
Activate the emergency fire alarm.
According to the RACE mnemonic, the second action in response to a fire is to activate the alarm.
Extinguish the fire.
According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire.
Confine the fire.
According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire.
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? - ANSWERS107 mL/hr
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
Palpate the client's abdomen before auscultating bowel sounds. - ANSWERSCorrect Answer:
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.
Incorrect Answers:
Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old.
Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum.
Palpate the client's abdomen before auscultating bowel sounds.
When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds.
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
"We can talk about advance directives, and I can also give you some brochures about them."
"You should set up a time to talk with your provider about that."
"Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better."
"Why do you want to discuss this without your partner here to plan this with you?" - ANSWERSCorrect Answer:
"We can talk about advance directives, and I can also give you some brochures about them."
With this statement, the nurse offers to provide the information the client needs in a direct and simple way.
Incorrect Answers:
"You should set up a time to talk with your provider about that."
The nurse is passing the responsibility of discussing this topic with the client to the provider, which dismisses the client's concerns.
"Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better."
The nurse is rejecting the client's needs by postponing a discussion about what is important to the client.
"Why do you want to discuss this without your partner here to plan this with you?"
Clients might interpret "why" questions as accusatory, and they can provoke feelings of mistrust and resentment.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
During the admission process
As soon as the client's condition is stable
During the initial team conference
After consulting with the client's family - ANSWERSCorrect Answer:
During the admission process
Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.
Incorrect Answers:
As soon as the client's condition is stable
Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability.
During the initial team conference
Team conferences facilitate discharge planning, but they are not essential for initiating the planning process.
After consulting with the client's family
The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
"I think I should take my pain medication more often, since it is not controlling my pain."
"Breathing faster will help me keep my mind off of the pain."
"It might help me to listen to music while I'm lying in bed."
"I don't want to walk today because I have some pain." - ANSWERSCorrect Answer:
"It might help me to listen to music while I'm lying in bed."
Listening to music is an effective nonpharmacological intervention for the management of mild pain.
Incorrect Answers:
"I think I should take my pain medication more often, since it is not controlling my pain."
As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time.
"Breathing faster will help me keep my mind off of the pain."
Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain.
"I don't want to walk today because I have some pain."
Postoperative clients need to ambulate even if they are having mild pain.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Neck vein distention
Urine specific gravity 0.99 (1.01 to 1.025)
Rapid heart rate
Blood pressure 144/82 mm Hg - ANSWERSCorrect Answer:
Rapid heart rate
Tachycardia is manifestation of fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.
Incorrect Answers:
Neck vein distention
Neck vein distension is a clinical manifestation of fluid volume excess.
Urine specific gravity 0.99 (1.01 to 1.025)
The urine specific gravity is expected to be greater than 1.025 for a client who has a potential fluid volume deficit. A decrease urine specific gravity may indicate overhydration or excess of fluid volume.
Blood pressure 144/82 mm Hg
Hypotension is an expected finding for a client who has fluid volume deficit.
A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
Rinse the feeding bag with water between feedings.
Tell the client to keep the head of the bed elevated at least 30°.
Make sure the enteral formula is at room temperature.
Wipe the top of the formula can with alcohol. - ANSWERSCorrect Answer:
Tell the client to keep the head of the bed elevated at least 30°.
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.
Incorrect Answers:
Rinse the feeding bag with water between feedings.
The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority.
Make sure the enteral formula is at room temperature.
The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority.
Wipe the top of the formula can with alcohol.
The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority.
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Limit the adolescent's visitors.
Select the food choices for the adolescent.
Allow the adolescent to make decisions regarding their daily routine.
Encourage the adolescent's guardian to assist with personal hygiene. - ANSWERSCorrect Answer:
Allow the adolescent to make decisions regarding their daily routine. [Show Less]