Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by
... [Show More] the nurse?
A. Surgical consent form is not signed
B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L)
C.Preoperative chest x-ray report is not available
D. Client's pulse oximeter reading is 96%
(Ans- B
One hour after major abdominal surgery, a client in the post anesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mmHg. Fifteen minutes later it is 114/72 mmHg. Which action should the nurse take first?
A. Increase frequency of BP assessments
B. Review the client's baseline BP trends
C. Check the abdominal surgical dressing
D. Encourage the client to breathe deeply
(Ans- C
The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function?
A. Ecchymotic area
B. Enlarged vein
C. Pulselessness
D. Redness
(Ans- B
Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
A. Encourage the client to lie down and rest after meals
B. Remind the client to avoid high-fiber foods
C. Teach the client to elevate the head of the bed on blocks
D. Instruct the client to use antacids only as a last resort
(Ans- C
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan?
A. Avoid driving a car for 2 weeks
B. Drink 3 liters of water each day
C. Eliminate all spicy foods from your diet
D. Clamp the catheter when taking a shower
(Ans- B
A client with chronic cirrhosis has esophageal varies. It is most important for the nurse to monitor the client for the onset of which problem?
A. Brown, foamy urine
B. Anorexia
C. Clay-colored stool
D. Hematemesis (Ans- A
After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
A. Irregular pulse rate
B. ST elevation in three leads
C. Complaint of radiating jaw pain
D. Bile colored emesis
(Ans- B
A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism?
A. Increased pulse rate
B. Diarrhea stools
C. Atrophied thyroid gland
D. Periorbital edema
(Ans- A [Show Less]