VERIFIED QUESTIONS AND SOLUTIONS
◉A nurse is providing care to a client who has spent several weeks
in the intensive care unit because of complications related to shock.
What adverse psychological outcomes should the nurse educate the
client about prior to transfer to the medical unit?
A. Hearing deficits and increased risk of glaucoma
B. Hypoxia and acidosis.
C. Bipolar behaviors and schizotypal behaviors.
D. Disorientation and depression. Answer: D. Disorientation and
depression
Clients in critical care units can experience adverse psychological
outcomes, such as disorientation from lack of sleep and depression
related to their illness.
◉A nurse is providing care for a client experiencing obstructive
shock. Which of the following diagnoses should the nurse expect?
A. Cardiac tamponade.
,B. Ruptured aneurysm
C. Third spacing
D. Cardiomyopathy. Answer: A. Cardiac tamponade.
Cardiac tamponade can result in obstructive shock as fluid or blood
buildup compresses the right ventricle, preventing cardiac
contraction and obstructing blood flow to the lungs.
◉A nurse is preparing to administer prescribed intravenous
potassium replacement supplements to a client who has a potassium
level of 2.5 mEq/L (3.5 to 5
mEq/L). Which of the following actions should the nurse plan to
include? (Select Al that Apply.)
A. Educate client regarding high-potassium food sources
B. Cardiac monitoring during infusion
C. Ensure that the client's urine output is at least 1 mL/kg/hour
D. Repeat blood serum potassium
E. Ensure potassium infusion is prepared with 5% dextrose solution.
Answer: A. Educate client regarding high-potassium food sources
B. Cardiac monitoring during infusion
C. Ensure that the client's urine output is at least 1 mL/kg/hour
D. Repeat blood serum potassium
,climb to lethal levels.
Assessing urine output is critical prior to administering potassium.
If the client is not able to filter and eliminate potassium due to
kidney disease, potassium may
The nurse should plan to use cardiac monitoring during intravenous
infusion of potassium. Lethal arrhythmias can occur.
It is important to repeat serum potassium during and following
intervention.
The nurse should plan to educate the hyponatremic client about
foods that are high in potassium to prevent future electrolyte
disturbances.
◉A nurse is providing discharge teaching to a client who has heart
failure (HF) and is on a diuretic. Which of the following statements
by the client indicates the
teaching was effective?
A. I plan to eat plenty of fruits and vegetables
B. " I should expect my blood pressure to be low when I stand."
C. "I will increase sodium i n my diet."
, D. "I should expect to experience occasional dizziness when I stand
up.". Answer: D. "I should expect to experience occasional dizziness
when I stand up."
Dizziness upon arising can indicate that the client is experiencing
fluid volume deficit related to the diuretic medication
◉A nurse is providing CPR to a client. Which of the following aspects
of CPR are different in the community versus in the hospital?
A. In the community, the nurse should notify emergency services.
B. Compression rates and depths vary depending on the setting.
C. In the hospital, codes are addressed by an interprofessional team.
D. In the community, the nurse might use laypeople for assistance.
E. In the community, the use of automated external defibrillators
(AEDs) requires the presence of a health care provider.. Answer: A.
In the community, the nurse should notify emergency services.
C. In the hospital, codes are addressed by an interprofessional team.
D. In the community, the nurse might use laypeople for assistance.
◉A nurse is planning care for a trauma client who has suspected flail
chest. Which of the following studies should the nurse identify as the
preferred method
for diagnosing flail chest?