A client is recovering from surgical repair of a dissecting aortic
aneurysm. Which assessment findings indicate possible bleeding or
recurring dissection?
Urine output of 15 ml/hour and 2+ hematuria
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Urine output of 150 ml/hour and heart rate of 45 beats/minute
Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute -
ANSWER Blood pressure of 82/40 mm Hg and heart rate of 125
beats/minute (Assessment findings that indicate possible bleeding or
recurring dissection include hypotension with reflex tachycardia (as
evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125
beats/minute), decreased urine output, and unequal or absent peripheral
pulses.)
What symptoms should the nurse assess for in a client with
lymphedema as a result of impaired nutrition to the tissue?
Loose and wrinkled skin
Ulcers and infection in the edematous area
Evident scarring
Cyanosis - ANSWER Ulcers and infection in the edematous area (In a
client with lymphedema, the tissue nutrition is impaired because of the
stagnation of lymphatic fluid, leading to ulcers and infection in the
edematous area.)
A nurse is caring for a client after cardiac surgery. Upon assessment,
the client appears restless and reports nausea and weakness. The
client's ECG reveals peaked T waves. The nurse reviews the client's
serum electrolytes, anticipating which abnormality?
Hyperkalemia
Hypercalcemia
Hypomagnesemia
, Hyponatremia - ANSWER hyperkalemia (Hyperkalemia is indicated by
mental confusion, restlessness, nausea, weakness, and dysrhythmias
(tall, peaked T waves))
A client who is postoperative day 1 following a CABG has produced 20
mL of urine in the past 3 hours and the nurse has confirmed the patency
of the urinary catheter. What is the nurse's mostappropriate action?
Document the client's low urine output and monitor closely for the next
several hours.
Contact the dietitian and suggest the need for increased oral fluid intake.
Contact the client's health care provider and continue to assess fluid
balance and renal function.
Increase the infusion rate of the client's IV fluid to prompt an increase in
renal function. - ANSWER Contact the client's health care provider and
continue to assess fluid balance and renal function. (An output of <0.5
mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral
is necessary.)
A nurse teaches a client with angina pectoris that he or she needs to
take up to three sublingual nitroglycerin tablets at 5-minute intervals and
immediately notify the health care provider if chest pain doesn't subside
within 15 minutes. What symptoms may the client experience after
taking the nitroglycerin?
Nausea, vomiting, depression, fatigue, and impotence.
Sedation, nausea, vomiting, constipation, and respiratory depression.
Headache, hypotension, dizziness, and flushing.
Flushing, dizziness, headache, and pedal edema. - ANSWER
Headache, hypotension, dizziness, and flushing.
A 56-year-old woman with severe varicose veins has opted for venous
ablation, and the nurse is providing patient education before the
scheduled procedure. What instructions should the nurse provide to this
patient?
"Try to limit your activity for the first 10 days to 2 weeks to prevent
reoccurrence of your varicose veins."
"You might experience some pain after the procedure, but this will be
managed with ice packs rather than medications."
aneurysm. Which assessment findings indicate possible bleeding or
recurring dissection?
Urine output of 15 ml/hour and 2+ hematuria
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Urine output of 150 ml/hour and heart rate of 45 beats/minute
Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute -
ANSWER Blood pressure of 82/40 mm Hg and heart rate of 125
beats/minute (Assessment findings that indicate possible bleeding or
recurring dissection include hypotension with reflex tachycardia (as
evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125
beats/minute), decreased urine output, and unequal or absent peripheral
pulses.)
What symptoms should the nurse assess for in a client with
lymphedema as a result of impaired nutrition to the tissue?
Loose and wrinkled skin
Ulcers and infection in the edematous area
Evident scarring
Cyanosis - ANSWER Ulcers and infection in the edematous area (In a
client with lymphedema, the tissue nutrition is impaired because of the
stagnation of lymphatic fluid, leading to ulcers and infection in the
edematous area.)
A nurse is caring for a client after cardiac surgery. Upon assessment,
the client appears restless and reports nausea and weakness. The
client's ECG reveals peaked T waves. The nurse reviews the client's
serum electrolytes, anticipating which abnormality?
Hyperkalemia
Hypercalcemia
Hypomagnesemia
, Hyponatremia - ANSWER hyperkalemia (Hyperkalemia is indicated by
mental confusion, restlessness, nausea, weakness, and dysrhythmias
(tall, peaked T waves))
A client who is postoperative day 1 following a CABG has produced 20
mL of urine in the past 3 hours and the nurse has confirmed the patency
of the urinary catheter. What is the nurse's mostappropriate action?
Document the client's low urine output and monitor closely for the next
several hours.
Contact the dietitian and suggest the need for increased oral fluid intake.
Contact the client's health care provider and continue to assess fluid
balance and renal function.
Increase the infusion rate of the client's IV fluid to prompt an increase in
renal function. - ANSWER Contact the client's health care provider and
continue to assess fluid balance and renal function. (An output of <0.5
mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral
is necessary.)
A nurse teaches a client with angina pectoris that he or she needs to
take up to three sublingual nitroglycerin tablets at 5-minute intervals and
immediately notify the health care provider if chest pain doesn't subside
within 15 minutes. What symptoms may the client experience after
taking the nitroglycerin?
Nausea, vomiting, depression, fatigue, and impotence.
Sedation, nausea, vomiting, constipation, and respiratory depression.
Headache, hypotension, dizziness, and flushing.
Flushing, dizziness, headache, and pedal edema. - ANSWER
Headache, hypotension, dizziness, and flushing.
A 56-year-old woman with severe varicose veins has opted for venous
ablation, and the nurse is providing patient education before the
scheduled procedure. What instructions should the nurse provide to this
patient?
"Try to limit your activity for the first 10 days to 2 weeks to prevent
reoccurrence of your varicose veins."
"You might experience some pain after the procedure, but this will be
managed with ice packs rather than medications."
