What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)? A. Have the client bear down when measuring the PCWP. B. Deflate the balloon as soon as the PCWP is measured. C. Place the client in a supine position before measuring the PCWP. D. Flush the catheter with… Read More »
The most important assessment for the nurse to make after a client has had a femoropopliteal bypass for peripheral vascular disease would be: A. Incisional pain B. Pedal pulse rate C. Capillary refill time D. Degree of hair growth Correct Answer: C. Capillary refill time Checking capillary refill provides… Read More »
Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply. A. Tachycardia B. Hypertension C. Increased CVP D. Decreased urine output E. Jugular vein distention Correct Answers: A, C, & D Cardiac tamponade is a medical or traumatic emergency that… Read More »
A client has the diagnosis of left ventricular failure and a high pulmonary capillary wedge pressure (PCWP). The physician orders dopamine to improve ventricular function. The nurse will know the medication is working if the client’s: A. Blood pressure rises B. Blood pressure decreases C. Cardiac index falls D. PCWP rises… Read More »
The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? A. Eat animal protein and dark leafy vegetables each day. B. Avoid exposure to others with acute infection. C. Practice yoga and meditation to decrease stress and anxiety.… Read More »
A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing… Read More »
A client comes into the health clinic 3 years after undergoing resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? A. “I have been drinking plenty of fluids.” B. “I have been gargling with warm salt… Read More »
A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A. Adds dried fruit to cereal and baked goods. B. Cooks tomato-based foods in iron pots. C. Drinks coffee or tea with meals. D.… Read More »
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client’s activity intolerance? A. “What activities were you able to do 6 months ago compared to the present?” B. “How long have you had this problem?” C.… Read More »
The primary purpose of the Schilling test is to measure the client’s ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12 Correct Answer: C. Absorb vitamin B12 Pernicious anemia is caused by the body’s inability to absorb vitamin… Read More »