NCLEX
A primipara patient asks the nurse the etiology of her physiological anemia. The nurse replied that in physiologic anemia of pregnancy, lower hemoglobin and hematocrit is due to: Select all that apply. 1. Increased blood volume 2. Increased cell mass 3. Iron utilization for fetal needs 4. Transfer of RBC from mother to fetus
1, 2, and 3. To provide an adequate exchange of nutrients in the placenta and to compensate for blood loss at birth, the circulatory blood volume of the woman's body increases at least 30% during pregnancy. The increase in blood volume occurs gradually near the end of the 1st trimester. It peaks at about the 28th to the 32nd wk and continues at this high level thru the 3rd trimester. As the plasma volume first increases, the concentration of hemoglobin and erythrocytes may decline, giving the woman a pseudoanemia. The fetus requires 350-450 mg of iron to grow. The increase in the mother's circulatory RBC mass requires an additional 400mg of iron. Iron absorption may be impaired during pregnancy as a result of decreased gastric acidity. Additional iron is often prescribed during pregnancy to prevent true anemia.
On physical examination, J.M.'s skin is warm and dry with poor skin turgor. She also has dry mucous membranes and dark-colored urine. Which vital signs would most likely correspond to these assessment findings? 1. BP: 100/62 lying, 104/64 sitting, 110/79 standing; HR: 102 lying, 100 sitting, 94 standing; Resp: 22; Temp: 37.2° C 2. BP: 100/62 lying, 85/60 sitting, 80/50 standing; HR: 102 lying, 114 sitting, 130 standing; Resp: 26; Temp: 38° C 3. BP: 120/82 lying, 110/64 sitting, 130/88 standing; HR: 80 lying, 70 sitting, 82 standing; Resp: 26; Temp: 37.0° C
Answer = 2. Poor skin turgor, dry mucous membranes, and dark-colored urine are symptoms of a fluid volume deficit. A falling blood pressure and increasing heart rate as the patient moves from a lying to a standing position depicts postural hypotension, which is also symptomatic of a fluid volume deficit.
The nurse is caring for a client diagnosed with genitourinary tuberculosis (TB). Which statement, made by the client, about genitourinary TB demonstrates an understanding? a) "It isn't infectious, and I can't pass it from one person to another." b) "It's an early manifestation of an autoimmune disorder." c) "It's a late manifestation of respiratory tuberculosis." d) "I can't pass it sexually to my partner."
C - Genitourinary TB is usually a late manifestation of respiratory TB and can occur if the disease spreads through the bloodstream from the lungs. Bacillus in the urine is infectious, and urine should be handled cautiously. A condom should be used during sex to prevent spread of the infection.
The client recovering from a PE is receiving a continuous infusion of heparin IV. When the nurse comes to take vital signs, the client has blood on his pajama jacket and pillow. He is pinching his nose to control a nosebleed. What is the nurse's best first action? A. Prepare to administer protamine sulfate parenterally. B. Prepare to administer phytonadione parenterally. C. Call the physician or Rapid Response Team. D. Slow the IV, and assess the bleeding.
C - Slow the IV, and assess the bleeding Rationale: Although the client is receiving IV heparin, this is not likely to be the cause of the bleeding. However, it should be slowed while you assess the client, to avoid increasing the bleeding time. Assess the client for a cause and for the severity of the bleeding before initiating other interventions. A) is incorrect as a first action. This drug is the antidote to heparin, but it may not be needed. A more thorough assessment is needed before this action should be initiated. B) is incorrect as a first action. The client is rational, trying to control his nosebleed. The severity of the bleeding needs to be assessed before calling the Rapid Response Team.
A newborn has undergone PlastiBell circumcision. The nurse has spoken with the parents about post-circumcision care to avoid complications. What should she do to minimize potential problems? 1. Check the infant for bleeding every 15 minutes for the first hour 2. Document if the infant has voided after the procedure 3. Observe for tenderness, redness, or if the baby cries 4. Teach the parents to keep the area clean and covered with petroleum
Check for bleeding q15 min for first hour. Complications that can occur after circumcision include hemorrhage, infection, and urethral fistula formation. To keep the risk to a minimum, the 1st priority of the RN is to check for bleeding q15 min for the 1st hour after the procedure. It is also important to document if the infant has voided after circumcision, but this is the secondary assessment. For first 3 days, parents should be taught how to keep the area clean and covered until healing is complete. Alert them to check the area often for any signs of redness, tenderness, constant crying from pain, or foul odor. Normally circumcision sites appear red, but they should never have a strong odor or discharge. A film of yellowish mucus often covers the glans by the 2nd day after surgery. Petroleum jelly should NOT be applied after circumcision when a PlastiBell is used.
A pregnant client's labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which of the following suggestions would be most helpful for the client's husband? a) "Keep a record of her contraction pattern." b) "Have her practice rapid, shallow breathing." c) "Suggest that she receive an epidural anesthetic." d) "Encourage her to rest between contractions."
D - Because the client has had prolonged labor, the client should be encouraged to rest as much as possible. In addition, the client should be encouraged to use appropriate breathing techniques, particularly slow chest breathing. Although the husband or significant other may keep track of the client's contraction pattern, this responsibility is that of the nurse caring for the client. Suggesting that she receive an epidural anesthetic is not appropriate because the client may desire natural childbirth methods. Rapid, shallow breathing or pant/blow breathing is inappropriate for this stage of labor because it can cause possible hyperventilation and lead to dizziness. This type of breathing is more appropriate for the transition stage of labor.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) take a hot bath. b) increase the dose of muscle relaxants. c) avoid naps during the day. d) rest in an air-conditioned room.
D - Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which of the following as the basis for the discussion? a) Chromosome translocation. b) Autosomal recessive gene. c) X-linked recessive gene. d) Chromosome deletion.
b - PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.
A pregnant client in her third trimester is started on chlorpromazine (Thorazine) 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the client's teaching plan? a) "Don't drive because there's a possibility of seizures occurring." b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." c) "Stop the medication immediately if constipation occurs." d) "Tell your doctor if you experience an increase in blood pressure."
b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." Reason: Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin. Therefore the client needs instructions about using sunscreen with a sun protection factor of 25 or higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and exercise. The drug does not need to be discontinued. Chlorpromazine is associated with postural hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as changing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: a) "Does water ever get into the baby's ears during shampooing?" b) "Do you give the baby a bottle to take to bed?" c) "Have you noticed a lot of wax in the baby's ears?" d) "Can the baby combine two words when speaking?"
b) "Do you give the baby a bottle to take to bed?" Reason: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.
A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying: a) Concreteness. b) Flight of ideas. c) Depersonalization. d) Use of neologisms
b) Flight of ideas. Reason: The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word made up by a client.
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? a) G 4, P 1 client who is breastfeeding her infant. b) G 3, P 3 client who is breastfeeding her infant. c) G 2, P 2 cesarean client who is bottle-feeding her infant. d) G 3, P 3 client who is bottle-feeding her infant.
b) G 3, P 3 client who is breastfeeding her infant. Reason: The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.
A 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 38 degrees C, heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a) Rectal diazepam (Diastat). b) IV lorazepam (Ativan). c) Rectal acetaminophen (Tylenol). d) IV fosphenytoin.
b) IV lorazepam (Ativan). Reason: IV ativan is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter, stopping seizure activity. If an IV line is not available, rectal Diastat is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery? a) Peritonitis. b) Thrombophlebitis. c) Ascites. d) Inguinal hernia.
b) Thrombophlebitis. Reason: After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Shock b) Encephalitis c) Increased intracranial pressure (ICP) d) Status epilepticus
c) Increased intracranial pressure (ICP) Reason: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy? a) Decrease in appetite. b) Drowsiness. c) Spasms of the diaphragm. d) Cough and shortness of breath.
d) Cough and shortness of breath. Reason: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.
A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I can't talk about that bastard right now. I just need to destroy something." Which of the following should the nurse do next? a) Tell her to write her feelings in her journal. b) Urge her to talk with the nurse now. c) Ask her to calm down or she will be restrained. d) Offer her a phone book to "destroy" while staying with her.
d) Offer her a phone book to "destroy" while staying with her. Reason: At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.