A client has a colon resection with Oliguria
an anastomosis. What assessments Irritability
by the nurse support a suspicion of Hypotension
impending shock? Select all that
apply. Decreased blood flow to the kidneys leads to oliguria or anuria.
1 Irritability, along with restlessness and anxiety, occurs because of a
Oliguria decrease in oxygen to the brain. Hypotension and a narrowing of the
2 pulse pressure occur because of declining blood volume.
Lethargy Restlessness, not lethargy, usually occurs because of decreased
3 cerebral blood flow. There are various changes in sensorium, but
Irritability slurred speech is not a manifestation of shock.
4
Hypotension
5
Slurred speech
,A client in the thirty-eighth week of A. "It increases blood flow to the fetus."
gestation exhibits a slight increase
in blood pressure. The primary The side-lying position decreases blood pressure and moves the
healthcare provider advises her to gravid uterus off the great vessels of the lower abdomen, increasing
remain in bed at home in a side- venous return, improving cardiac output, and promoting kidney and
lying position. The client asks why placental perfusion. The side-lying position does not influence intra-
this is important. What is the nurse's abdominal pressure. While a pregnant woman is on bed rest the blood
response regarding the advantage pressure decreases. The side-lying position does not prevent
of this position? thrombosis; bed rest and immobility may increase the risk of
1 thrombosis.
"It increases blood flow to the
fetus."
2
"It decreases intra-abdominal
pressure."
3
"It increases the mean arterial
pressure."
4
"It prevents the development of
thrombosis."
, A client undergoes removal of a Maintain the head of the bed at a 30-degree angle continuously
pituitary tumor through a
transsphenoidal approach. What Maintaining the head of the bed at a 30-degree angle continuously
should the nurse implement decreases pressure on the sella turcica and promotes venous return,
postoperatively? thus limiting cerebral edema. Gentle oral hygiene is performed,
1 excluding brushing of teeth, to prevent trauma to the surgical site.
Provide oral hygiene and include Although deep breathing is encouraged, initially coughing is
brushing the teeth discouraged to prevent increasing intracranial pressure. There is no
2 need to limit oral fluids because of the presence of nasal packing.
Encourage the client to deep
breathe and cough frequently
3
Maintain the head of the bed at a
30-degree angle continuously
4
Continue giving nothing by mouth
until the nasal packing is removed
an anastomosis. What assessments Irritability
by the nurse support a suspicion of Hypotension
impending shock? Select all that
apply. Decreased blood flow to the kidneys leads to oliguria or anuria.
1 Irritability, along with restlessness and anxiety, occurs because of a
Oliguria decrease in oxygen to the brain. Hypotension and a narrowing of the
2 pulse pressure occur because of declining blood volume.
Lethargy Restlessness, not lethargy, usually occurs because of decreased
3 cerebral blood flow. There are various changes in sensorium, but
Irritability slurred speech is not a manifestation of shock.
4
Hypotension
5
Slurred speech
,A client in the thirty-eighth week of A. "It increases blood flow to the fetus."
gestation exhibits a slight increase
in blood pressure. The primary The side-lying position decreases blood pressure and moves the
healthcare provider advises her to gravid uterus off the great vessels of the lower abdomen, increasing
remain in bed at home in a side- venous return, improving cardiac output, and promoting kidney and
lying position. The client asks why placental perfusion. The side-lying position does not influence intra-
this is important. What is the nurse's abdominal pressure. While a pregnant woman is on bed rest the blood
response regarding the advantage pressure decreases. The side-lying position does not prevent
of this position? thrombosis; bed rest and immobility may increase the risk of
1 thrombosis.
"It increases blood flow to the
fetus."
2
"It decreases intra-abdominal
pressure."
3
"It increases the mean arterial
pressure."
4
"It prevents the development of
thrombosis."
, A client undergoes removal of a Maintain the head of the bed at a 30-degree angle continuously
pituitary tumor through a
transsphenoidal approach. What Maintaining the head of the bed at a 30-degree angle continuously
should the nurse implement decreases pressure on the sella turcica and promotes venous return,
postoperatively? thus limiting cerebral edema. Gentle oral hygiene is performed,
1 excluding brushing of teeth, to prevent trauma to the surgical site.
Provide oral hygiene and include Although deep breathing is encouraged, initially coughing is
brushing the teeth discouraged to prevent increasing intracranial pressure. There is no
2 need to limit oral fluids because of the presence of nasal packing.
Encourage the client to deep
breathe and cough frequently
3
Maintain the head of the bed at a
30-degree angle continuously
4
Continue giving nothing by mouth
until the nasal packing is removed
