d.
Improve the oxygen capacity of the blood.
It is important to prevent venous Stasis by increasing the flow of venous return. Options # 1 and #2 will increase the riskassociated with DVT. Option #4 will not affect the course of deep vein thrombosis.
16.
Ipecac syrup has been given to a client after accidental ingestion of a poisonous plant. Which nursing observation ismost important to report to the next shift?a.
No vomiting has occurred after dose was given.b.
An antiemetic has been ordered and given.c.
A slight increase in temperature has been noted.d.
The client will be NPO until the next day.
No response to Ipecac after the dose should be reported to next shift and the physician for further action. Options #2 and#3 are nones-sential. Option #4 is not a high priority
17.
A client with chronic lung disease is admitted to the acute pulmonary unit with: respiratory rate of 50; pulse of 140 andirregular; skin pale and cool to touch; client confused as to place and time. Orders are: oxygen per nasal cannula at4L/minute, bedrest, soft diet and pulmonary function tests in the AM. What is the best sequence of nursing activities?a.
Place in semi-Fowler's position, begin the oxygen, have someone stay with the client, then notify the doctorregarding the current status of the client.b.
Begin the oxygen, call the nursing supervisor, keep the bed flat to maintain blood pressure, and stimulateclient to take deep breathsc.
Call the nursing supervisor, discuss with the family if the client has experienced this problem before, offer theclient sips of clear liquidsd.
Advise respiratory therapy of the client's problem, place the client in semi-Fowler's position, and begin theoxygen.
The doctor's orders do not address the seriousness of the client's condition. The doctor should be notified immediately.However, the client should not be left alone. Options #2, #3, and #4 do not address the seriousness of the client'simmediate needs.
18.
The nurse arrives for the day shift and receives her assignments around 7:30 a.m. The assignment includes:
• a man with a diagnosis of rule
-out an MI. He is on a monitor and having 4-6 premature beats per hour.
• an elderly lady who is confused and h
as constant urinary dribbling.
• a pneumonia client with increasing confusion and a temperature of 104° at 6:30 a.m.
• a diabetic client who experienced a restless night and 7:00 a.m. blood sugar was 170mg%.
Which client is a priority and how should the nurse plan her care?a.
The pneumonia client has priority; his condition should be assessed immediately.b.
The elderly lady is probably wet and uncomfortable and should be taken care of first. Then obtain a stat bloodglucose to determine the diabetic client's current blood sugar level.c.
The cardiac client should be assessed immediately as the monitor indicates cardiac irritability. Then thetemperature on the pneumonia client should be reassessed.d.
The diabetic client should be seen immediately to assess for evidence of hyperglycemia. Then the pneumoniaclient should be assessed for patency of airway.
The sickest client is the pneumonia client, and his needs should be addressed first. This client has an increased temperature,which may indicate his pneumonia is getting worse; and his confusion may be indicative of hypoxia. His status should beevaluated immediately. Premature beats of 4
—
6 per hour are benign and not unusual for a cardiac client. The elderly ladymay be uncomfortable, but the respiratory status of the pneumonia client is priority. A blood sugar of 170 mg% is abnormallyhigh and should be addressed. However, the respiratory status of the pneumonia client is the highest priority.
19.
Which nursing observation is most important to report to the physician on a client with a second-degree thermal injury toright arm?a.
Pain around the periphery of injury.b.
Gastric pH less than 6.0.c.
Increased edema of right arm.d.
An elevated hematocrit.
A decrease in gastric pH could indicate the hypersecretion of hydrogen ions
—
a predisposing factor to stress ulcer formation.Options #1, #3, and #4 are expected findings in burn wound resolution.
20.
In planning health teaching about the Recombivax immunization against Hepatitis, it is most important to include:a.
recombivax is given at specific intervals in a series of three.b.
the immunization can only be given IM.c.
allergic reactions are possible since human plasma is used.d.
recombivax has been associated with AIDS
The necessity of completing the series of three injections is an important factor to include in education concerning immuniza-tion with Recombivax. Options #2, #3, and #4 contain false information.
21.
A postoperative client is receiving bupivacaine hydrochloride (Marcaine) for pain through an epidural catheter. Whichresponse should the nurse recognize as desirable for this pain management technique?a.
Decreased respirations.b.
Somnolence.c.
Decreased restlessness.d.
Decreased blood pressure.
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