,ASSESSMENT1
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. Which of the following
actions should the nurse take
A. Warm the dialysate in the microwave
B. Weigh the client before and after each dialysis treatment
C. Place the drainage bag at the level of the client's dialysis catheter
D. Wear clean gloves when providing peritoneal catheter care - answer-B. Weigh the client before and
after each dialysis treatment
This determines the amount of fluid removed
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which of the following actions
should the nurse take to prepare the client for the procedure
A. Advise the client that a chest xray will be necessary following the procedure
B. Inform the client that the procedure requires general anesthesia
C. Place the client in a supine position
D. Instruct the client to take deep breaths during the procedure - answer-A. Advise the client that a
chest xray will be necessary following the procedure chest X ray verifies that a pneumothorax or a
mediastinal shift has not occurred
A nurse is caring for a client who has developed a pulmonary embolus (PE). Which of the following
assessment findings should the nurse expect
A. bradycardia
B. lethargy
C. sharp chest pain
D. petechiae over lower extremities - answer-C. sharp chest pain
A nurse on an ICU is caring for a client who has developed ventricular fibrillation. Which of the following
actions is the nurses priority A. Defibrillate the client
B. Apply oxygen for the client
,C. Provide chest compressions for the client
D. Administer epinephrine to the client - answer-A. Defibrillate the client
Vfib is a lethal rhythm, ventricles are quivering and has no cardiac output and must be defibrillated! If
Vfib continues after one shock, then deliver CPR and airway management
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following
actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - answer-A
Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and
paper, etc
B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia.
Turn the client q 2hr to prevent complications related to immobility
C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning
on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal
mucosa
D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the
following laboratory results indicates effectiveness of the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - answer-C
Within the expected range of 1.005-1.030
A, sodium range is 136-145
B, potassium range is 3.5-5
D, Hct range is 37%-52%
, A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip
arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million - answer-C platelet range is 150,000-400,000 A, PT range is 11-12.5
B, aPTT range is 30-40 seconds
D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not
indicate that the client is at risk for bleeding
A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which
of the following interventions is the nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - answer-D
The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to
ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing)
A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings
indicates that the client is experiencing transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - answer-C
Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension,
bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an
anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP
A, nausea can indicate an acute hemolytic transfusion reaction
B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic D,
bradycardia is not an indication
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