Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
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Solution
Urine output greater than 30ml/hr
Option A: Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
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Solution
Administering Coumadin
Option B: Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except:
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Solution
gastric distension
Option D: Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
What is the peak age range for acquiring acute lymphocytic leukemia (ALL)?
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Solution
4 to 12 years.
Option A: The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
Lydia is scheduled for elective splenectomy. Before the client goes to surgery, the nurse in charge final assessment would be:
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Solution
vital signs
Option B: An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
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Solution
Bleeding tendencies
Option C: Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
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Solution
dairy products
Option A: Good source of vitamin B12 are dairy products and meats.
Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
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Solution
Potential alteration in renal perfusion
Option D: There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
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Solution
High levels of low-density lipid (LDL) cholesterol
Option A: An increase in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
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Solution
headache
Option C: Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension, and dizziness.