HESI study
Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education? "I would administer intravenous analgesia." "I would prepare for an endotracheal intubation." "I would anticipate the need for a fiberoptic bronchoscopy." "I would immediately calculate the burned surface area with the rule of nines."
"I would immediately calculate the burned surface area with the rule of nines." Inhalation injury burns occur in the nose, mouth, throat, and airway. The nurse would administer intravenous analgesia and anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy. Inhalation burns are not visible or limited to the nose, mouth, throat, and airway; there are not any calculations, because the surface area is internal.
A client with third-degree burns asks the nurse, "Why do I need a temporary pigskin graft?" Which response by the nurse is appropriate? "It helps debride necrotic tissue." "It promotes rapid healing of the wound." "When sutured in place, it provides better adherence." "Topical lotions can be used concurrently with the graft."
"It promotes rapid healing of the wound."
When a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take? Administer oral fluids. Encourage deep breathing. Increase the oxygen flow rate. Perform nasotracheal suctioning
Encourage deep breathing. Hypoventilation because of pain is the usual cause of respiratory acidosis after chest surgery and the nurse would encourage deep breathing to help eliminate excess carbon dioxide. Oral fluids are helpful in liquefying respiratory secretions, but will not increase respiratory rate or depth to eliminate carbon dioxide. Increasing oxygen flow rate would be used to treat hypoxemia, but will not decrease carbon dioxide levels in the blood. Suctioning would help eliminate excessive secretions if the client was unable to cough effectively, but would not decrease carbon dioxide levels.
When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? An irreversible phenomenon A failure of the circulatory pump Usually a fleeting reaction to tissue injury Generally caused by decreased blood volume
A failure of the circulatory pump
The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. Which is an important assessment the nurse needs to perform before beginning the pump? Checking for the last bowel movement. Checking for residual stomach contents. Determining the time of the last nausea medication. Determining the client's comfort level.
Checking for residual stomach contents.
A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. A diagnosis of gastric ulcer is made. Which is the primary nursing concern? Chronic pain Risk for injury Electrolyte imbalance Inadequate gas exchange
Electrolyte imbalance
After a myocardial infarction, a client asks the nurse, "What's the chance of me having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse? Identifying the concerns and helping the client explore feelings Telling the client that it is important to be especially careful with diet and stress Suggesting that the client discuss the feelings of vulnerability with the primary health care provider Understanding that the client is frightened and suggesting a talk with the psychiatric nurse
Identifying the concerns and helping the client explore feelings
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which concern is the nurse's priority? Loss of skin integrity caused by the burns Potential infection as a result of the burn injury Inadequate gas exchange caused by smoke inhalation Decreased fluid volume because of the depth of the burns
Inadequate gas exchange caused by smoke inhalation
During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, which clinical finding would the nurse expect the client to manifest? Diminished visual acuity Increased muscular weakness Pronounced muscular atrophy Impairment in cognitive reasoning
Increased muscular weakness
A client who is obese has an abdominal cholecystectomy. How would the nurse plan to alleviate tension on the surgical wound after surgery? Limiting deep breathing Maintaining T-tube patency Maintaining nasogastric tube patency Encouraging the right side-lying position
Maintaining nasogastric tube patency
Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? Monitor for cardiac dysrhythmias. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.
Monitor for cardiac dysrhythmias. Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia
Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? Chest tube insertion Aggressive diuretic therapy Administration of beta-blockers Positive end-expiratory pressure (PEEP)
Positive end-expiratory pressure (PEEP)
Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider? High anxiety level Elevated troponin T Urine output 15 mL/h Heart rate 58 beats/minute
Urine output 15 mL/h
Which action would be the nurse's first priority when receiving a client with major burns? Assessing airway patency Checking the client from head to toe Administering oxygen as needed Elevating the extremities if no fractures are noticed
assessing airway patency
When the nurse is obtaining the health history for a client with mitral valve stenosis, which question will be most relevant to ask? "Do you frequently get urinary tract infections?" "Have you had a recent episode of pneumonia?" "Did you ever have strep throat during childhood?" "Do you have a family history of heart attack or angina?"
"Did you ever have strep throat during childhood?" Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. The nurse may obtain information about other infections, but urinary tract infection is not associated with risk for mitral stenosis. Mitral stenosis does not increase pneumonia risk and is not caused by recent pneumonia. The nurse may ask about family history of heart disease, but history of coronary artery disease or myocardial infarction does not increase risk for valve disease.
A person sustains severe burns of the arms and is waiting for emergency services to arrive. The nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. Which response by the nurse is best? "Let's focus on sitting quietly with the victim while waiting for the ambulance." "Let's cover up the victim with one of those tablecloths instead." "Let's apply first aid cream to the burns rather than the butter." "Let's get that butter on quickly."
"Let's cover up the victim with one of those tablecloths instead." A tablecloth is typically not fuzzy and nonadhering and will keep the burned person warm. Doing nothing is inappropriate; body heat should be conserved with a nonadhering covering. Cream is difficult to remove and may result in additional damage. Butter is contraindicated for the treatment of burns.
The nurse is discussing discharge instructions with a client who had a myocardial infarction. The client asks, "When will it be safe to have sex again?" Which response by the nurse is best? "Usually it takes several weeks for the heart to heal enough for sexual activity." "The health care provider will discuss sexual activity with you before you leave the hospital." "Many clients are not really interested in sexual activity for several weeks after having a heart attack." "One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs."
"One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs."
When the pulse rate for a client with a recent myocardial infarction increases from 70 beats/minute to 135 beats/minute while climbing the stairs, which instruction would the cardiac rehabilitation nurse give to the client? "Continue climbing." "Stand still and rest." "Walk down the stairs." "Climb but at a slower rate."
"Stand still and rest."
A client weighing 132 pounds (60 kilograms) with burns over 35% of the body arrives at the hospital an hour after being rescued from a fire. Which amount of lactated Ringer solution would the nurse anticipate being infused in the next 8 hours?
4200 ml In the first 8 hours, 4200 mL should be infused. According to the Parkland (Baxter) formula, one-half of the total daily amount of fluid should be administered in the first 8 hours. the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours.
The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. How would the nurse interpret this finding? Fluid is leaking into the intestine. The pancreas has been lacerated. This is a typical, expected response. A biliary vessel has been punctured.
A biliary vessel has been punctured The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy. Fluid will leak through the puncture site or into the peritoneum, not the intestine. The pancreas does not contain bile; it is in the upper left, not upper right, quadrant. This is a complication, not an expected outcome.
A client who had a myocardial infarction has runs of ventricular tachycardia. Which medication will the nurse prepare to administer? Digoxin Furosemide Amiodarone norepinephrine
Amiodarone Amiodarone decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. It is used in the treatment of ventricular dysrhythmias such as ventricular tachycardia. Digoxin slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats. Furosemide, a diuretic, does not affect ectopic foci. Norepinephrine is a sympathomimetic and is not the medication of choice for ventricular irritability.
When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? Select all that apply. One, some, or all responses may be correct. Change the ostomy pouch on a routine basis. Replace the ostomy wafer weekly or sooner as needed. Remove the ostomy pouch when showering. Empty the ostomy pouch when 3/4 full of stool or gas. Empty the ostomy pouch before exercise and at bedtime
Change the ostomy pouch on a routine basis. Replace the ostomy wafer weekly or sooner as needed. Empty the ostomy pouch before exercise and at bedtime
After abdominal surgery, a client's postoperative prescriptions include a nasogastric (NG) tube to lower intermittent wall suction and an antiemetic every 6 hours as needed for nausea. When the client reports feeling nauseated, which action would the nurse take first? Check for correct placement of the NG tube. Administer the prescribed antiemetic. Assess the client's bowel sounds. Notify the primary health care provider.
Check for correct placement of the NG tube. With a nasogastric (NG) tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking its placement can determine whether it is in the stomach; once placement is verified, fluid then can be instilled to ensure patency. The antiemetic may relieve the discomfort, but it will not determine the cause. Auscultation of the client's abdomen should occur with the nurse's other assessments, but it will not help determine the cause of the nausea. The nurse should assess the situation before notifying the health care provider.
Which information about a client who is being discharged 3 days after having an ST segment elevation myocardial infarction (STEMI) and coronary artery stent placement indicates that a home health referral may be needed at discharge? ST segments have not yet returned to baseline. Troponin T and Troponin I levels are still elevated. Client reports frequently forgetting to take medications. Pulse increases from 65 beats/minute to 75 beats/minute with exercise.
Client reports frequently forgetting to take medications.
When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority? Defibrillate the client. Notify the Rapid Response Team. Administer intravenous epinephrine. Initiate cardiopulmonary resuscitation.
Defibrillate the client.
Which action will the nurse take when measuring a client's pulmonary artery wedge pressure (PAWP)? Deflate the balloon as soon as the PAWP is measured. Have the client bear down when measuring the PAWP. Place the client in high-Fowler position to measure the PAWP. Advance the catheter if a typical PAWP tracing is not obtained.
Deflate the balloon as soon as the PAWP is measured. Although the balloon must be inflated to measure the PAWP, it is deflated as soon as the PAWP is obtained to allow blood to continue to flow through the pulmonary artery. Bearing down will increase intrathoracic pressure and lead to an inaccurate PAWP reading. The client would be positions in a supine position at 0 to 45 degrees for PAWP measurement. Repositioning of the catheter may be done by the health care provider, but is not within the scope of nursing practice. Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.
The nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary health care provider prescriptions would the nurse do first? Draw peripheral blood cultures from two different sites. Administer levofloxacin 500 mg intravenously over 30 minutes. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. Take the client to x-ray for an abdominal computed tomography (CT) scan.
Draw peripheral blood cultures from two different sites Because this client is hemodynamically stable, the priority is to draw the blood cultures so that the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation
A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis? Electromyography Pyridostigmine test Edrophonium chloride test History of physical deterioration
Edrophonium chloride test
When planning discharge teaching for a client who had coronary artery bypass graft (CABG) surgery using a vein graft, which information will the nurse include? Call immediately if you experience any incisional pain. Mild fever is expected for several weeks after a CABG. Elevate the leg that provided the vein graft whenever you are sitting. Avoid walking or light housework until after the follow-up appointment.
Elevate the leg that provided the vein graft whenever you are sitting. Because the leg that provided the vein graft is likely to be edematous after surgery, the client should keep the leg elevated when possible. Incisional pain is expected for several weeks, and the client will be prescribed medication for pain control and should not need to call because of pain. Elevated temperature for a few days after surgery is normal, but fever occurring after discharge should be reported to the health care provider. Walking a few hundred feet and doing light housework are appropriate activities after discharge. More vigorous exercise or lifting heavier objects should be avoided until after seeing the health care provider or being evaluated in a cardiac rehabilitation program.
The nurse is evaluating a client who has been receiving medical intervention for a diagnosis of Crohn disease. Which expected outcome is most important for this client? Performs skin care Tolerates oral fluids Experiences less abdominal cramping Gains a half pound (0.2 kilograms) per week
Gains a half pound (0.2 kilograms) per week Weight loss usually is severe with Crohn disease; therefore, weight gain is a priority. This goal is specific, realistic, and measurable and has a time frame. Although skin care, tolerating oral fluids, and experiencing less abdominal cramping are important, they are not as high a priority as weight gain.
The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow?
High caloric intake, liberal potassium intake, and 3 g protein/kg per day A high-calorie diet is needed for the increased metabolic rate associated with burns; the administration of potassium prevents hypokalemia, which can occur after the first 48 to 72 hours when potassium moves from the extracellular compartment into the intracellular compartment; protein promotes tissue repair. High caloric intake, restricted potassium intake, and 1 g protein/kg per day do not meet the body's needs for tissue repair; the protein and potassium are too limited. Moderate caloric intake, liberal potassium intake, and 3 g protein/kg per day do not meet the body's needs for tissue repair; the calories are too limited. Moderate caloric intake, restricted potassium intake, and 1 g protein/kg per day do not meet the body's needs for tissue repair; the calories, potassium, and protein are too limited.
Which nursing action is priority when a client with severe chest pain and diaphoresis is brought to the emergency department? Initiate electrocardiogram (ECG) monitoring. Obtain a health history from the client. Ask the client about usual alcohol intake. Start a normal saline intravenous infusion
Initiate electrocardiogram (ECG) monitoring. Because fatal dysrhythmias are the most common cause of death with acute coronary syndrome, the nurse's first action would be to start ECG monitoring. Obtaining a health history is important, but can be done after cardiac monitoring is established. The nurse will ask about usual alcohol intake, but this information can be obtained after cardiac monitoring is started. Having intravenous access is essential to administer medications and treat dysrhythmias, but can be done after ECG monitoring is started.
Which finding would the nurse expect in a client with left-side phrenic nerve paralysis? Bibasilar crackles Coarse-sounding rhonchi Left lung expiratory wheezes Left base dullness to percussion
Left base dullness to percussion
Which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm? Administering supplemental oxygen Maintaining a low blood pressure Keeping the client in a supine position Monitoring the femoral and pedal pulses
Maintaining a low blood pressure Monitoring pulses distal to the aneurysm will help identify whether an aneurysm has ruptured, but it will not prevent rupture.
A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? Palpating the neck or face Evaluating the blood gases Auscultating the lung fields Reviewing the chest x-ray film
Palpating the neck or face Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Gas exchange and thus blood gases are not affected. The lungs are not affected.
The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client? Ptosis and dysphagia Paresthesias and paralysis Atrophy and fasciculations Muscle weakness and drooling
Paresthesias and paralysis Guillain-Barré syndrome includes the clinical manifestations of paresthesia and paralysis result from patchy demyelination of the peripheral nerves, nerve roots, root ganglia, and the spinal cord. Ptosis and dysphagia relate to myasthenia gravis. Atrophy and fasciculations relate to amyotrophic lateral sclerosis. Muscle weakness and drooling relate to Parkinson disease.
When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? Right atrial pressure Central venous pressure Pulmonary artery diastolic pressure Pulmonary artery wedge pressure
Pulmonary artery wedge pressure Pulmonary artery wedge pressure (PAWP) is an indirect measure of left ventricular end-diastolic pressure. Right atrial pressure measures only the function of the right side of the heart, which frequently does not reflect left ventricular function. Central venous pressure (CVP) is the same as right atrial pressure, because the large central veins are contiguous with the right atrium. CVP also reflects right-sided cardiac pressures and is not usually a good indicator of left ventricular function. Pulmonary artery diastolic pressure is frequently a good indicator of left ventricular end-diastolic pressure, but may be inaccurate in clients with chronic obstructive pulmonary disease or pulmonary hypertension.
A client is admitted to the hospital with a diagnosis of a large, cancerous tumor of the sigmoid colon, and surgery for a colon resection is scheduled. Which clinical finding would the nurse expect when completing the client's nursing admission history and physical? Diarrhea Dehydration Rectal bleeding Ribbon-shaped stool
Rectal bleeding Tumors of the sigmoid colon are associated with rectal bleeding. Diarrhea alternating with constipation frequently occurs. Dehydration usually does not occur unless there is severe vomiting or severe prolonged diarrhea. A change in the shape of stool occurs with tumors in the descending colon and sigmoid colon.
Which finding in a client seen in the emergency department with chest pain is most important to communicate to the health care provider? Severe nausea and vomiting Substernal pain level 9 (0 to 10 scale) Blood glucose 230 mg/dL (12.78 mmol/L) ST segment elevation on electrocardiogram
ST segment elevation on electrocardiogram
Which statement reflects understanding of sepsis screening requirements by the nurse? Blood cultures are required to diagnosis sepsis and begin sepsis protocols. An oral temperature of 96.4°F (35.8°C) is not an indicator of sepsis. A primary health care provider's prescription is required to screen for sepsis. Sepsis mortality is affected greatly by treatments performed in the first 6 hours
Sepsis mortality is affected greatly by treatments performed in the first 6 hours
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? The partial pressure of oxygen (PO2) value is 80 mm Hg. The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). Serum potassium value is 4 mEq/L (4 mmol/L).
The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). The HCO3 value is elevated. The urinary system compensates by retaining hydrogen (H+) ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO3 value is 21 to 28 mEq/L (21-28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis the PCO2 level may be increased, it is the increased HCO3 level that indicates compensation. A potassium (K+) level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5-5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.
A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? Works at a plumbing business Works in a hemodialysis unit at a hospital Works as a dishwasher at a local restaurant Works at an occupational arsenic compound business
Works at a plumbing business Hepatitis A primarily is spread via a fecal-oral route; sewage-polluted water may harbor the virus. Working at a hemodialysis unit is closely linked to hepatitis types B, C, and D; these types are more often spread via the blood-borne route. Using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. Working as a dishwasher at a local restaurant does not increase the risk of developing the disease, but it will increase the risk of an infected individual spreading the disease to others. Exposure to arsenic or carbon tetrachloride will not cause hepatitis A.
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. Monitoring vital signs Cutting off the clothing Inserting a urinary catheter Removing the client's jewelry Establishing an intravenous line
all of these According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.
A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client? Select all that apply. One, some, or all responses may be correct. Fever Tachypnea Hypertension Abdominal rigidity Increased bowel sounds
fever, tachypnea, abdominal rigidity The metabolic rate will be increased, and the temperature-regulating center in the hypothalamus resets to a higher-than-usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.
The nurse is assessing a client with severe liver disease. Which assessment finding will the nurse expect to observe? Icterus Urticaria Uremic frost Hemangioma
icterus Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.
The nurse will anticipate the need to administer which type of medication when a client with cardiogenic shock has an increased pulmonary artery wedge pressure reading of 30 mm Hg? Vasopressor Loop diuretic Antidysrhythmic Beta-adrenergic blocker
loop diuretic Increased pulmonary artery wedge pressure indicates increased left ventricular preload; the nurse will anticipate the need to decrease preload by administration of a loop diuretic. A vasopressor would not decrease ventricular preload and vasopressors are not usually used in cardiogenic shock because they increase cardiac workload and oxygen demand. There is no indication that the client has a dysrhythmia and antidysrhythmic treatment is not indicated. A beta-adrenergic blocker would decrease cardiac output and likely increase left ventricular preload.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? Cyanosis Bradycardia Mental confusion Distended neck veins
mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).
Which client has second-degree burns?
moist blebs, blisters, severe pain
A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. Oliguria Bradypnea Diaphoresis Tachycardia Hypertension
oliguria, tachycardia, diaphoresis
When the nurse is caring for a client who has cardiogenic shock, which clinical manifestations will be expected? Select all that apply. One, some, or all responses may be correct. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output
rapid pulse, decreased urinary output The heart rate increases (tachycardia) to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.
A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood? Water sports Strenuous exercises Sleeping with pillows High-humidity environment
water sports Water sports pose a severe threat; should water enter the stoma, the client will drown. Strenuous exercises are not harmful; as long as there is no obstruction, adequate oxygen will be available because the respiratory rate will increase. Pillows are not contraindicated, although care should be taken not to occlude the airway by any bedding while asleep. Humidity is desirable and helpful in keeping secretions liquefied.
A client is prone to hyponatremia. Which factors would the nurse identify that can precipitate hyponatremia? Select all that apply. One, some, or all responses may be correct. Wound drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate antidiuretic hormone (ADH) secretion
wound drainage, diuretic therapy, GI suction, inappropriate ADH secretion
