Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?
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Solution
Altered mental status and dehydration
Options B, C, and D: Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia.
Option A: Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?
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Solution
The client is oriented when aroused from sleep and goes back to sleep immediately.
Option C: This finding suggests that the level of consciousness is decreasing.
A client has undergone spinal anesthetic, it will be important that the nurse immediately position the client in:
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Solution
Flat on back.
Option B: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be caused by the seepage of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.
A client underwent ileostomy, when should the drainage appliance be applied to the stoma?
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Solution
In the operating room.
Option B: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated.
A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
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Solution
Continue treatment as ordered.
Option B: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.
Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should:
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Solution
Make sure that the client takes food and medications at prescribed intervals.
Option C: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate.
Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
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Solution
Call for help and note the time.
Option A: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure.
In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:
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Solution
Decreasing venous return through vasodilation.
Option D: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard.
A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
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Solution
Check respirations, stabilize spine, and check circulation
Option C: Checking the airway would be the priority, and a neck injury should be suspected.
Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?
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Solution
On the client’s right side
Option A: The client has left visual field blindness. The client will see only from the right side.