Med-surg
The nurse is providing post-partum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? (Select All that apply) A.
A, B, C, and D Rationale: The postpartum client should wear a bra that is a well fitted and supportive. Breast feeding clients should increase daily fluid intake; having bottled water available for on the go. Decrease amount of caffeine while breast-feeding. No alcohol. Prescription medications can affect milk supply, and should only be taken if prescribed by PCP.
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? A. "I should sleep on my left side." B. "I should sleep on my right side." C. "I should sleep with my head flat." D. "I should not wear my glasses at any time."
A. "I should sleep on my left side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client should be placed in a semi-fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.
A 2-year old child is treated in the ER for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicated an understanding of measures to provide safety in the home? A. "We will be sure not to leave hot liquids unattended." B. "I guess our children need to understand what the words hot means." C. "We will be sure that the children stay in their rooms when we work in the kitchen." D. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."
A. "We will be sure not to leave hot liquids unattended." Rationale: Toddlers, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen while preparing coffee and other hot items. Always turn pan handles on the stove inward, and toward the middle of the stove. All other options are not reasonable.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. A. Respirations that are shallow B. Respirations that are increased in rate C. Respirations that are abnormally slow D. Respirations that are abnormally deep E. Respirations that cease for several seconds
B & D. Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.
The nurse evaluates the ability of a Hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? A. The mother requests that the window be closed before feeding B. The mother holds the newborn properly during feeding and burping C. The mother tests the temperature of the formula before initiating feeding D. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding the baby.
D. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding the baby. Rationale: Hepatitis B is a highly contagious virus transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals and to avoid maternal complications.
The nurse instructs a client with Chronic Kidney Disease (CKD) who is receiving hemodialysis about dietary modifications. The nurse determines the client understand these dietary modifications if the client selects which item from the dietary menu? A. Cream of wheat, blueberries, coffee B. Sausage and eggs, banana, orange juice C. Bacon, cantaloupe melon, tomato juice D. Cured pork, grits, strawberries, orange juice
A. Cream of wheat, blueberries, coffee Rationale: The diet for a client which Chronic Kidney Disease who is receiving hemodiaylsis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. The food items in the remaining options are high in sodium, phosphorus, and/or potassium
A client has been admitted to the hospital for Gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drop to which value? A. 3mg/dL B. 15mg/dL C. 29 mg/dL D. 35mg/dL
B. 15mg/dL Rationale: The normal BUN level is 10 to 20 mg/dL. Values of 29mg/dL and 35mg/dL reflect continued dehydration. A value of 3mg/dL reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.
The nurse is providing instructions to a pregnant client with a hx of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? A. "I should increase my sodium intake during pregnancy." B. "I should lower my blood volume by limiting my fluids." C. "I should maintain a low-calorie diet to prevent any weight gain." D. "I should drink adequate fluids and increase my intake of high-fiber foods."
D. "I should drink adequate fluids and increase my intake of high-fiber foods." Rationale: Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by primary care provider, because excess salt (sodium) would cause circulatory overload which would cause the client further cardiac complications. Diets low in fluids can cause hypovolemia, causing harm to mom and the baby.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heartbeat of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A. Decreased pH and an increased PaCO2 B. Increased pH and a decreased PaCO2 C. Decreased pH and a decreased HCO3 D. Increased pH and an increased HCO3
D. Increased pH and an increased HCO3. Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 to increase.
The nurse is caring for a client with Cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches about foods that are high in Thiamine. The nurse understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? A. Milk B. Chicken C. Broccoli D. Legumes
D. Legume Rationale: The client with cirrhosis needs to consume foods high in Thiamine. Legumes are especially rich in Thiamine. Other good food sources include nuts, whole grain cereals, and pork.
The nurse is teaching a client who has iron deficiency anemia about foods she should include in their diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? A. Nuts and milk B. Coffee and tea C. Cooked rolled oats and fish D. Oranges and dark green leafy vegetables
D. Oranges and dark green leafy vegetables. Rationale: Dark green leafy vegetables are a good source of iron, and oranges are a good source of Vitamin C, which enhances iron absorption. All other options are not high enough in iron and Vitamin C.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PaCO2 is 90, and HCO3 is 22. The nurse interprets the results as indicating which condition? A. Metabolic acidosis with compensation B. Respiratory acidosis with compensation C. Metabolic acidosis without compensation D. Respiratory acidosis without compensation
D. Respiratory acidosis without compensation. Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45. The normal HCO3 is 22-28. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition the pH is not within normal limits. Therefore, the condition is without compensation.
