Which of the following signs and symptoms would alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy
A. Increased blood pressure and decreased pulse and respiratory rates.
B. Sanguineous drainage from the chest tube at a rate of 50 mL per hour during the past 3 hours.
C. Restlessness and shortness of breath.
D. Urine output of 180 mL during the past 3 hours.
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The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems
A. Depression is commonly characterized by pain disorders and somatic complaints.
B. Combining evaluations will save time and allow for quicker delivery of health care.
C. Most insurance plans won’t cover evaluation of both as separate entities.
D. The physician doesn’t have the training to evaluate for psychosocial considerations.
The nurse is caring for a client with an acute bleeding cerebral aneurysm. Which of the following activities is not appropriate in nursing care
A. Position the client to prevent airway obstruction.
B. Keep the client in one position to decrease bleeding.
C. Administer IV fluid as ordered and monitor the client for signs of fluid volume excess.
D. Maintain the client in a quiet environment.
Which of the following would the nurse interpret as indicating that a child is receiving too much intravenous fluid too rapidly
A. Marked increase in abdominal girth.
B. Evidence of protein in the urine.
C. Dark amber colored urine.
D. Moist crackles in the lung fields.
Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following
A. Nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
Bed rest for the first 8 hours after a treatment.
C. Assessment of short-term memory loss.
D. No special car
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