Clinical Judgment (adaptive quizzing)
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
Answer: 6 A score of 8 or below indicates coma. The Glasgow Coma Scale is used to assess the extent of neurologic damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.
An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment?
Answer: apparent shortening of one leg The affected leg appears to be shorter because the femoral head is displaced upward. The child's ability to abduct, not adduct, the affected leg is limited. Narrowing of the perineum with an anal stricture does not occur with hip dysplasia. When the femoral head slips out of the acetabulum, it is palpable.
Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets should the nurse administer? Record your answer using a whole number.
Answer: 2 0.6 X 1000 = 600 1200/600 = 2
The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response?
Answer: A 15-month-old toddler client The ASQ developmental screening tool is appropriate to use for pediatric clients from 1 month to 4.5 years of age. The nurse would use this screening tool for the 15-month-old toddler. The other clients are not within the age range for the use of the ASQ screening tool.
The nurse manager of the pediatric unit is notified that four children are going to be admitted to the unit. Which of the following children should be placed nearest the nurse's station?
Answer: An infant with acute laryngotracheobronchitis. An infant with the diagnosis of laryngotracheobronchitis should be close to immediate help because breathing is essential to life. If the airway becomes obstructed, the nurse must act quickly to prevent brain damage. Although children with fractures, sickle cell crisis, and thrombocytopenic purpura all require monitoring, their conditions are not as critical as that of a child with a potential airway problem.
A client has a pulse deficit. Which documentation by the nurse supports this finding?
Answer: Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.
A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate?
Answer: Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.
Which biologic agent of terrorism is treated with antitoxin?
Answer: Botulism Botulism is treated with antitoxin, though several vaccines are being studied. Plague and anthrax can be treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant. Smallpox can be prevented or the incidence reduced by vaccination, even when first given after exposure.
A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?
Answer: Brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades over time. A patchy loss of skin pigmentation indicates vitiligo.
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?
Answer: Circulatory collapse The clinical symptoms of monoamine oxidase inhibitors (MAOIs) generally appears after 12 hours of ingestion. Circulatory collapse is associated with MAOI toxicity. Mydriasis, bradycardia, and hyperthermia are not associated with an isocarboxazid overdose.
The nurse is planning to triage clients after a disaster. Which client does the nurse categorize into the green-tagged category?
Answer: Client D patient with bruises and lacerations. The disaster triage tag system categorizes triage priority by color. Clients with minor injuries that can be managed in a delayed fashion are categorized as green-tagged. Therefore client D with bruises and lacerations on the skin is green-tagged. Client A, with the life-threatening condition of an airway obstruction is red-tagged. Client B with large wounds and open fractures needs treatment within 30 minutes to 2 hours and is yellow-tagged. Client C with critical massive head trauma is black-tagged.
Which drug would be effective for the treatment of pituitary Cushing's syndrome?
Answer: Cyproheptadine Cyproheptadine is effective for the treatment of pituitary Cushing's syndrome. Mitotane is prescribed for the treatment of adrenal Cushing's syndrome. Cabergoline and bromocriptine mesylate are effective for the treatment of hyperpituitarism.
Which is the function of the medical command physician according to the Emergency Preparedness and Response Plan?
Answer: Deciding the number, acuity, and resource needs of clients The function of the medical command physician, according to the Emergency Preparedness and Preparedness Plan, is deciding the number, acuity, and resource needs of clients. The function of the community relations or public information officer is serving as a liaison between the healthcare facility and the media. The function of the hospital incident commander is assuming overall leadership for implementing the emergency plan. The function of the triage officer is evaluating each client rapidly to determine priorities for treatment.
A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean due to cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which nursing action should be taken after the initial physical assessment?
Answer: Determine the blood glucose level The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant. There are no data that indicate a need for oxygen. Formula will not be given at this time, and there are no data that indicate a need for gavage feeding. The situation does not indicate the need for transfer of the newborn to the neonatal intensive care unit. The Apgar scores demonstrate that this infant is adapting to extrauterine life.
A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain?
Answer: Fluid retention With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).
In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time?
Answer: Having the client empty her bladder A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. Therefore the bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not accurate; the uterus will not remain contracted over a full bladder.
A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?
Answer: Hemorrhage After transurethral surgery [1] [2], hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs it will manifest later in the postoperative course. Phlebitis is assessed for, but it is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the IV catheter is not a major complication.
A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?
Answer: High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.
A nurse in the pediatric unit is admitting an 8-year-old child with asthma after an exacerbation at home. The child is short of breath. In what position should the child be placed to facilitate breathing and to promote respiratory drainage?
Answer: High-Fowler The high-Fowler position gives the lungs more room to expand, thereby promoting respiration and affording more comfort. The supine, left lateral, and Trendelenburg positions will all increase dyspnea; they do not permit chest expansion.
Which step in the research process is similar to the assessment step of the nursing process?
Answer: Identifying the problem which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.
Which intervention is a part of the response phase of disaster planning?
Answer: Implementing the disaster plan The response phase of disaster management deals with the implementation of the disaster plan. The recovery phase of disaster management involves stabilizing the community. Mitigation focuses on limiting the impact of a disaster. The last phase of disaster management focuses on evaluation of the plan.
Which characteristic that may pose a potential nutrition problem should the nurse identify in a preterm neonate?
Answer: Inadequate sucking reflex The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting. The metabolic rate is increased because of fatigue and growth needs. The digestive process is slow, especially in regard to the ability to digest lipids. Absorption of nutrients is decreased because the gastrointestinal tract is immature.
An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress?
Answer: Increased eosinophil level Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions. Platelets and lymphocytes are unrelated to allergic reactions. Immunoglobulins increase, not decrease, in response to an allergic reaction.
Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?
Answer: Increased intracranial pressure (ICP) Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.
A teenager with allergies is using oxymetazoline nasal spray. What effect should the nurse assess the client for if more than the recommended dose is taken?
Answer: Increased nasal congestion With frequent and continued use, oxymetazoline can cause rebound congestion of mucous membranes. Nasal polyps may be associated with allergies but are unrelated to nasal spray use. Ringing in the ears (tinnitus) is not associated with oxymetazoline, although this medication may cause hypotension, tachycardia, and dizziness. Bleeding tendencies are related to inadequate clotting mechanisms, which are not associated with the use of this nasal spray.
A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child?
Answer: Isolation room An isolation room is a private room fitted with special air handling and ventilation to prevent the transmission of airborne droplet nuclei 5 micrometers or smaller. It has monitored negative pressure to prevent air from moving from the room into the corridor of the facility. Room air is exchanged 6 to 12 times an hour to the outdoors or through a monitored high-efficiency filtration system. Mycobacterium tuberculosis remains suspended in the air for prolonged periods and is transmitted in air currents. A private room does not have the technical equipment to manage airborne droplet nuclei of 5 micrometers or smaller. Other children and people on the unit will be exposed to the infected individual's pathogens that travel through air currents. A four-bed room or semiprivate room will expose the children and other people on the unit to the infected individual's pathogens.
A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child?
Answer: Keeping the child from inflicting any self-injury. All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.
Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?
Answer: Monitoring for seizures Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.
A school-aged child is admitted to the hospital with severe burns on the arms. Therapeutic escharotomy is planned. What is the priority nursing action at this time?
Answer: Monitoring radial pulses Eschar is rigid and may restrict circulation and lead to loss of limb perfusion. Blisters are associated with superficial and deep partial-thickness burns; eschar is associated with full-thickness burns. Blisters are not removed because they protect the underlying skin. Maintaining airborne precautions is unnecessary; the client is not the source of infection but must be protected from infection because the first line of defense has been compromised. Performing passive range-of-motion exercises is unnecessary.
A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include?
Answer: Obtaining a prescription to administer Rho(D) immune globulin to the mother Rho(D) immune globulin will prevent sensitization resulting from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive newborn. Determining the father's blood type is unnecessary because only the mother's and infant's Rh factors are relevant. Preparing for a maternal blood transfusion is unnecessary; if a transfusion were needed, it would be for the newborn, not the mother. There is no ABO incompatibility; incompatibility might occur if the mother were O positive and the newborn had type A, B, or AB blood.
A 6-year-old child has a fractured arm and multiple old injuries. Child maltreatment is suspected. What parental characteristic supports this suspicion?
Answer: Offering inconsistent stories about the injuries. Typically, abusive parents resist questioning; however, when pressured to explain the injuries they offer a variety of stories in an attempt to cover up the real origin of the injuries. Abusive parents display little interest in the child's care or progress. Rather than guilt, battering parents tend to feel angry at the child for the injury. An abusive parent typically has difficulty showing concern for the child. The parent is unable to comfort the child, such as through touch, and gives little indication of realizing how the child feels.
An older female client is seen in the primary healthcare provider's office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch (2.5 cm) since the last visit 1 year ago. The nurse knows that what is the most likely reason for this finding?
Answer: Older adults may have osteoporosis-related height changes. Because of the decreasing amounts of estrogen in older women, there is a loss of calcium as well, which can lead to bone loss and a loss in height. Most likely the nurse was not in error because of the age of the client and likelihood of osteoporosis. Sweeping statements about older adults not being active enough or having poor posture are not accurate.
After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be?
Answer: Perform a complete pain assessment A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be caused by neurovascular trauma to the affected leg, and the intervention for each is different. Notifying the primary healthcare provider, using distraction techniques, and medicating the client as prescribed may be done after a complete assessment reveals that this is the appropriate intervention; assessment is the priority.
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Answer: Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques. Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.
A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?
Answer: Placing the prescribed as-needed warm, wet compress on the elbow Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the primary healthcare provider is called. Telling the adolescent to wait provides no comfort.
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider?
Answer: Potassium 3.0 mEq/L (3.0 mmol/L)A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm 3is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L). Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.
What services can be provided by level II trauma care centers during mass causality events?
Answer: Provide care to most injured clients level II trauma care are community-based trauma centers that can provide most trauma care to clients. Level III trauma centers can provide care up to the stabilization of clients. A full continuum of trauma services for all clients is provided in Level I trauma centers. Basic trauma client stabilization and advanced life support are provided in Level IV trauma centers. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.
The victims of a terrorist attack involving sarin are brought to the emergency department. Which statement does the nurse know to be true regarding the characteristics of sarin?
Answer: Sarin can cause death within minutes of exposure. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. Mustard gas causes skin burns and blisters. A garlic-like odor and brown color are characteristics of mustard gas. While pralidoxime chloride (2-PAM chloride) is used as an antidote for nerve agent poisoning, multiple doses may be needed to reverse the effects of nerve agents; also, sarin is highly toxic and can cause death within minutes of exposure.
A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child?
Answer: Sitting on nurse's lap, leaning forward. In order to perform a postural drainage in a 4-year-old child, the nurse should place the child sitting on the nurse's lap, leaning forward against a pillow. In order to perform a postural drainage of the apical segments of adults, the client should sit on the side of the bed. In order to perform a right upper lobe drainage in an adult, the client should be the supine position with the head elevated. In order to perform a drainage of both lower lobes in an adult, the client should lie supine in Trendelenburg position.
A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations?
Answer: Systemic responses of the body to a localized inflammatory process With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).
A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating?
Answer: Too busy to take the time to eat Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.
A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites?
Answer: impaired portal venous return The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.
A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse?
The toddler is exhibiting typical behavior for this developmental level; most toddlers will say no as a means of asserting their independence. Although the child may be eager to resume playing, the behavior described is related to the child's assertion of autonomy. Although toddlers who are attempting to assert independence will say no even when they mean yes, they do understand the difference. This child's behavior does not indicate confusion; it is typical of 2-year-old children, who will say no to most things as a means of asserting their independence.
A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition?
Answer: Asking the parents to visit at mealtimes Dinner is frequently a family activity. Having the parents visit during meals may provide the child with additional emotional, social, and physical support, resulting in improved nutritional intake. The child will be resentful if fed by a staff member. Providing diversional activity at mealtimes may further inhibit the child's nutritional intake. Eliminating the child's between-meal snacks may not influence the child's overall intake; snacks may be preferred and will provide a source of nutrition.
A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion?
Answer: Assess the client's respiratory status The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.
Which assessment is expected when a client is placed in the lithotomy position during physical examination?
Answer: Assessment of the female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.
The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?
Answer: Azotemia The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO 2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.
A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first?
Answer: Record the observation and continue to monitor the drainage from the tube. Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.
A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone?
Answer: Respiratory rate and level of consciousness Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
answer: Continuing to observe the seizure The child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. Oxygen is useless until the child breathes when the seizure is over. The practitioner may be notified later; provisions for the child's safety and observation are the priorities.