The nurse assumes care of a postoperative adult client with diabetes mellitus and
learns that the client has a current blood glucose level of 720 mg.
... [Show More] When assessing the
client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate. - CORRECT ANSWER-A. Assess for vital signs
of fluid volume deficit.
A male client tells the nurse that he is concerned that he may have a stomach ulcer
because he is experiencing heartburn and a dull gnawing pain. Which is the *best*
response by the nurse?
A. Encourage the client to obtain a complete physical exam since these symptoms are
consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food.
C. Instruct the client that these mild symptoms can generally be controlled with changes
in his diet.
D. Advise the client that he needs to seek immediate medical evaluation and treatment
for these symptoms. - CORRECT ANSWER-A. Encourage the client to obtain a
complete physical exam since these symptoms are consistent with an ulcer.
A male client with stomach cancer returns to the unit following a total gastrectomy. He
has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after
admission to the unit, the nurse notes 300 mL of blood in the suction canister, the
client's heart rate is 155 beats/minute. In addition to reporting the findings to the
surgeon, which action should the nurse implement *first?*
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution. - CORRECT ANSWER-D.
Increase the infusion rate of Lactated Ringer's solution.
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering
a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at
18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose
Injection 250 mL. The nurse should program the infusion pump to how many mL/hour? -
CORRECT ANSWER-18
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a
right pneumothorax. Chest tubes were inserted in the emergency department prior to
his transfer to the intensive care unit (ICU). The nurse notes that the suction control
chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over
the past hour 75 mL of bright red blood is measured in the collection chamber. Which
intervention should the nurse implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water seal - CORRECT ANSWER-A.
Add sterile water to the suction control chamber.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is imminent
because their two adult children want to be there when he dies. Which is the *best*
response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will slow
down.
C. Reassure the spouse that the healthcare provider will notify when to call the children.
D. Offer to discuss the client's health status with each of the adult children. - CORRECT
ANSWER-B. Explain that the client will start to lose consciousness and the body
systems will slow down.
The charge nurse of a critical carry unit is informed at the beginning of the shift that
lesss than the optical number of registered nurses will be working that shift and planning
assignments which client should receive the most care hours by registered nurse (RN)?
A. 48 year olds marathon runner with a central venous catheter who is experiencing
nausea and vomiting due to electrolyte disturbance following a race
B. 34 year old admitted today after an emergency appendectomy who has a peripheral
intravenous catheter and a Foley catheter
C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen
via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has
a Foley catheter and soft wrist restraint supplied - CORRECT ANSWER-D. An 82-yearold's client with Alzheimer's disease and newly fractured femur who has a Foley
catheter and soft wrist restraint supplied
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750
mg/2.4 mL." How many mL should the nurse administer? - CORRECT ANSWER-0.2
In caring for a client with Cushing's syndrome which serum laboratory value is most
important for the nurse to monitor?
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin - CORRECT ANSWER-C. Glucose
A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute.
The client is manifesting shortness of breath bilateral 2+ pedal edema in an oxygen
saturation on a room air of 89% which action should the nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis - CORRECT ANSWER-C. Begin supplemental
oxygen
When caring for a client with full thickness burns to both lower extremities, which
assessment findings warrant immediate invention? (Select all that apply)
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses.
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds - CORRECT ANSWER-B. Complaint [Show Less]