Fundamentals - Physiological Aspects

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1.Increase fluid intake. 2.Restrict fluids. 3.Encourage early mobility. 4.Elevate the knee gatch of the bed

3.Encourage early mobility.

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1.Do not change positions suddenly. 2.Light-headedness is a common adverse effect that need not be reported. 3.The medication may cause a sore throat for the first few days. 4.Schedule blood tests weekly for the first 2 months

1.Do not change positions suddenly.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? 1.Nausea 2.Urticaria 3.Photophobia 4.Yellow vision

1.Nausea

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? 1.Monitor the EEG. 2.Assess for dizziness. 3.Administer the drug after meals. 4.Assess for dark, tarry stools.

2.Assess for dizziness.

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1.Early ambulation 2.Coughing and deep breathing 3.Wearing anti-embolic elastic stockings 4.Maintenance of a nasogastric tube

2.Coughing and deep breathing

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1.Rapid, thready pulse 2.Distended jugular veins 3.Elevated hematocrit level 4.Increased serum sodium level

2.Distended jugular veins

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1.Sodium 2.Potassium 3.Calcium 4.Calcitonin

2.Potassium

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1.Pull the fire alarm on the unit. 2.Remove anyone that is in immediate danger. 3.Obtain a fire extinguisher and report to the fire area. 4.Close all windows and fire doors and await further instructions

2.Remove anyone that is in immediate danger.

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1.Ask the registered nurse start the client's infusion at a peripheral site 2.Slow the rate of the client's infusion of the TPN 3.Interrupt the client's infusion and notify the charge nurse or health care provider 4.Obtain the vital signs and continue monitoring the client's status

3.Interrupt the client's infusion and notify the charge nurse or health care provider

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1.Normal serum electrolyte levels 2.Healthy skin integrity 3.Resolution of peripheral edema 4.Improved hemoglobin and hematocrit levels

4.Improved hemoglobin and hematocrit levels

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1.Sodium 2.Calcium 3.Chloride 4.Potassium

4.Potassium

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1."You need to try to be patient. The client is going through a lot right now." 2."I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3."Just ignore it and get on with your work. I'll assign someone else to take a turn." 4."The client's frightened and taking it out on the staff. Let's think of approaches we can take.

4."The client's frightened and taking it out on the staff. Let's think of approaches we can take.