The nurse is providing care for a patient on postoperative day 1 following a craniotomy. The patient's urine output is 1500 mL over 2 hours. What should the nurse suspect?

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Question 1 of 5

The nurse is providing care for a patient on postoperative day 1 following a craniotomy. The patient's urine output is 1500 mL over 2 hours. What should the nurse suspect?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which action by the nurse is most appropriate?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer: A

Rationale: Encouraging the patient to increase oral fluids, unless contraindicated, is the most effective initial intervention to manage copious tracheobronchial secretions in pneumonia. Hydration thins mucus, making it easier to mobilize and clear from the airways, thus reducing the work of breathing. Oral suctioning is inadequate for tracheobronchial secretions as it only addresses the mouth and throat, not deeper airways. Lying in a low Fowler's or supine position worsens secretion pooling and impairs breathing, contradicting the goal of improving respiratory function. Increasing activity may be beneficial later but is impractical during acute respiratory distress due to fatigue and oxygen demand. Adequate hydration supports mucociliary clearance, a critical mechanism impaired in pneumonia, and aligns with evidence-based care to prevent further complications like atelectasis or worsening infection.

Question 4 of 5

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?

Correct Answer: A

Rationale: Aspiration risk is highest in patients with impaired swallowing or protective airway reflexes, such as the gag, laryngeal, and cough reflexes, which are frequently disrupted by a severe stroke. Stroke-related dysphagia stems from neurological damage to cranial nerves (e.g., IX, X), leading to uncoordinated swallowing and silent aspiration, especially within weeks of the event when recovery is incomplete. Mid-stage Alzheimer's typically affects cognition more than motor swallowing function, with dysphagia emerging later. A 92-year-old needing ADL help may have frailty but not necessarily swallowing impairment unless tied to a specific condition. Severe rheumatoid arthritis causes joint deformity, not typically dysphagia, unless secondary issues (e.g., cervical spine involvement) affect swallowing, which isn't indicated. The stroke patient's recent neurological insult makes them most vulnerable, requiring the nurse to prioritize swallowing assessments and interventions like modified diets or speech therapy.

Question 5 of 5

A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patients oxygenation status at the bedside?

Correct Answer: B

Rationale: Monitoring pulse oximetry is the best bedside method to assess oxygenation status during thrombolytic therapy for pulmonary embolism (PE), providing real-time, noninvasive measurement of oxygen saturation (SpO2). It reflects how effectively oxygen reaches the blood despite PE-induced ventilation-perfusion mismatch, guiding adjustments in oxygen therapy (e.g., aiming for SpO2 >90%). Serial arterial blood gases (ABGs) are precise but invasive, time-consuming, and not practical for continuous bedside use. Pulmonary function tests assess airway obstruction or restriction, not acute oxygenation, and are irrelevant here. Incentive spirometry measures inspiratory effort, aiding atelectasis prevention, not oxygenation. Pulse oximetry's immediacy and simplicity enable the nurse to detect hypoxemia promptly, ensuring timely intervention (e.g., increasing FiO2) as thrombolytics dissolve the clot, critical in this dynamic, high-risk scenario.

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