MED/SURG NCLEX-RN HESI
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The
client is very restless and has scant urine
... [Show More] output. Oxygen is being administered at 2
L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds. - ANS-B
The client is at risk for hypovolemic shock because of the postoperative status and is
exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to
restore tissue perfusion. (A, C, and D) are all important interventions, but are of less
priority than (B).
During a health fair, a male client with emphysema tells the nurse that he fatigues
easily. Assessment reveals marked clubbing of the fingernails and an increased
anteroposterior chest diameter. Which instruction is best to provide the client?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine." - ANS-A
Manifestations of emphysema include an increase in AP diameter (referred to as a
barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to
promote energy management, such as pacing activities and scheduling rest periods (A).
(B) may result in a decreased drive to breathe. The client is not exhibiting any
symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).
During the change of shift report, the charge nurse reviews the infusions being received
by clients on the oncology unit. The client receiving which infusion should be assessed
first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin - ANS-C
All four of these clients have the potential to have significant complications. The client
with the morphine epidural infusion (C) is at highest risk for respiratory depression and
should be assessed first. (A) can cause hypotension. The client receiving (B) is at
lowest risk for serious complications. Although (D) can cause nephrotoxicity and
phlebitis, these problems are not as immediately life threatening as (C).
The nurse is planning care for a client with diabetes mellitus who has gangrene of the
toes to the midfoot. Which goal should be included in this client's plan of care?
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