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Questions 148

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Question 1 of 5

A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?

Correct Answer: D

Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.

Question 2 of 5

The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?

Correct Answer: D

Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.

Question 3 of 5

The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:

Correct Answer: B

Rationale: Guillain-Barre syndrome typically shows elevated protein levels in cerebrospinal fluid with a normal cell count, known as albuminocytologic dissociation.

Question 4 of 5

The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.

Correct Answer: C,D,E

Rationale: Ensuring understanding of treatment options, obtaining an interpreter, and discussing advance directives promote client autonomy and rights. Other actions assume incapacity or impose personal views.

Question 5 of 5

The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:

Correct Answer: D

Rationale: Increased bile-tinged drainage may indicate a complication, such as a leak, requiring physician notification.

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