Nr 326 / Nr326 Ati Mental Health Final Exam Study Guide. Questions And Answers With Rationales.
148. A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? A. Check for hypertension. B. Auscultate for loud, bounding heart sounds. C. Auscultate blood pressure for pulsus paradoxus. D. Check for a pulse deficit. Rationale: The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles. 149. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride Rationale: Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products. 150. A nurse is preparing to transfuse 250 mL of packed RBCs to a patient over four hours. Available is a blood administration set that delivers 10 GTT/mL The nurse should set the manual blood transfusion to deliver how many GTT/min? )Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) 10 gtt/min 10 gtt / 1 mL x 250 mL / 4 hrs x 1 hr / 60 min = 2,500 gtt / 240 min = 10. -- 10 gtt/mi
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