Evidence
Which intravenous fluid should the nurse classify as hypertonic?
5% dextrose in normal saline
A client has a leak of thoracic duct following a radical neck surgery. The nurse expects that the postoperative plan of care will include:
A chest tube, total parenteral nutrition (TPN), and bed rest A chest tube drains the leaking chyle from the thoracic area; TPN provides nutrition, boosts immune defenses, and decreases thoracic duct flow. Bed rest is recommended because lymphatic flow increases with activity.
An adult client sustains partial- and full-thickness burns of the left thigh, left arm, and head. Using the Lund-Browder chart, the nurse calculates that the percentage of total body surface area burned is:
According to the Lund-Browder chart the total body surface area is calculated: left thigh = 9.5%, left arm = 7%, and head = 7%, which totals 23.5%. 16.5%, 28.5%, and 30.5% are incorrect calculations.
A nurse is caring for a client who reports urinary problems, and the health care provider prescribes a cholinergic medication. Which response is prevented that helps the nurse determine that the medication is effective?
Bladder flaccidity Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention . Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder.
A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment?
Increased breath sounds The chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function
A client with psychosis is receiving olanzapine (Zyprexa, Zydis). What is important for the nurse to consider when administering this drug?
It dissolves instantly after oral administration Olanzapine (Zyprexa, Zydis) is an orally disintegrating tablet, meaning that it will instantly dissolve on contact with moisture
A client is admitted to the hospital with a possible diagnosis of Addison disease. What is an important nursing responsibility during a 24-hour urine collection for this client?
Keeping the client quiet and reducing stress Stress and activity increase the secretion of adrenocorticotropic hormone (ACTH) and adrenocortical hormones, elevating the urine values for the byproducts of these hormones, thus invalidating the test results.
A client with C8 tetraplegia is admitted to the emergency room. He develops a blood pressure of 80/40 mm Hg, pulse 48 beats/min, and respiratory rate (RR) of 18 breaths/min. The nurse suspects which condition?
Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin caused by the loss of adrenergic stimulation below the level of the lesion
A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.
Pallor Tachycardia Narrow pulse pressure
A client is at risk for increased intracranial pressure (ICP). Which of the following assessment findings reflects an increase in ICP?
Unequal pupil size Increased ICP causes unequal pupils as a result of pressure on the third cranial nerve.
A practitioner prescribes divalproex (Depakote) for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit?
Dizziness, nausea, and vomiting Divalproex (Depakote), an anticonvulsant, causes gastric irritation and should be taken with food; it is available in an enteric-coated form. It may cause nausea, vomiting, indigestion, hypersalivation, diarrhea or constipation, anorexia or increased appetite, dizziness, headache, and confusion
On the first day of the month a practitioner prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg?
The client will reach the desired dosage of 175 mg on the 13th day of the month; on the first day it is 25 mg, on the third day it is 50 mg, on the fifth day it is 75 mg, on the seventh day it is 100 mg, on the ninth day it is 125 mg, on the 11th day it is 150 mg, and on the 13th day it is 175 mg.
