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1. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct answer: B
Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.
2. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Position the client in a side-lying position.
- B. Perform the irrigation using a 20-mL syringe.
- C. Instill 15 mL of irrigation fluid into the catheter with each flush.
- D. Measure and record the amount of irrigant used.
Correct answer: B
Rationale: When irrigating an indwelling urinary catheter, the nurse should use a 20-mL syringe for the procedure. This syringe size helps to provide adequate pressure for effective irrigation. Placing the client in a side-lying position is not necessary for this procedure. Instilling a specific amount of irrigation fluid into the catheter is not mentioned in the scenario. Subtracting the amount of irrigant used from the client's urine output is not a standard practice in catheter irrigation.
3. The counting of sponges is done by the Surgeon together with the:
- A. Circulating nurse
- B. Scrub nurse
- C. Assistant surgeon
- D. Nurse supervisor
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
4. A client is being taught by a nurse about the correct use of a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale for 1 second
- B. Hold the inhaler 1-2 inches from the mouth
- C. Exhale immediately after inhaling
- D. Hold the inhaler directly at the lips
Correct answer: B
Rationale: The correct instruction the nurse should include when teaching a client about using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance ensures proper delivery of the medication into the airways. Choices A, C, and D are incorrect because inhaling for a specific duration, exhaling immediately after inhaling, or holding the inhaler directly at the lips are not recommended practices for the correct use of an MDI.
5. A nurse is caring for a client with thrombocytopenia. Which action is the highest priority to reduce the risk of bleeding?
- A. Use an electric razor instead of a straight razor.
- B. Apply pressure to any bleeding sites for at least 5 minutes.
- C. Avoid invasive procedures unless absolutely necessary.
- D. Monitor for signs of internal bleeding.
Correct answer: C
Rationale: The highest priority action to reduce the risk of bleeding in a client with thrombocytopenia is to avoid invasive procedures unless absolutely necessary. Thrombocytopenia is a condition characterized by a low platelet count, which impairs the blood's ability to clot properly. By avoiding invasive procedures, the nurse minimizes the potential for bleeding episodes that could be challenging to control due to the low platelet count. Using an electric razor instead of a straight razor (Choice A) is a good practice to prevent cuts, but it is not as critical as avoiding invasive procedures in this scenario. Applying pressure to bleeding sites (Choice B) and monitoring for signs of internal bleeding (Choice D) are important interventions but are secondary to the priority of preventing bleeding by avoiding invasive procedures.
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