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Question 1 of 5

A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should

Correct Answer: B

Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order

Question 2 of 5

The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?

Correct Answer: A

Rationale: will see dyspnea, cough, edema, hemoptysis

Question 3 of 5

The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?

Correct Answer: B

Rationale: intake and output

Question 4 of 5

A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which Ivanof the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?

Correct Answer: B

Rationale: daily weight is the best way to evaluate for fluid volume deficit

Question 5 of 5

A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?

Correct Answer: B

Rationale: BP should always be taken on the opposite arm from the graft

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