Nokea
The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
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The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?
- A. Help the child enroll in a special education class.
- B. Allay any feelings of guilt the parents may have.
- C. Explain to the parents that medications are lifelong.
- D. Teach the parents how to set limits.
Correct Answer: B
Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.
Based on this strip, what is the correct interpretation of this rhythm?
- A. Atrial fibrillation.
- B. Premature atrial fibrillation.
- C. AV block.
- D. Ventricular tachycardia.
Correct Answer: A
Rationale: The correct interpretation of the rhythm strip is atrial fibrillation. This arrhythmia is characterized by an irregular heartbeat and the absence of distinct P waves. Choice B, premature atrial fibrillation, is incorrect as there is no indication of premature beats in the strip. Choice C, AV block, is also incorrect as there is no evidence of conduction delays between the atria and ventricles. Choice D, ventricular tachycardia, is not supported by the absence of wide QRS complexes typically seen in this arrhythmia.
A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?
- A. No. When the lesions have disappeared, you may stop the nystatin.
- B. Yes. You should continue it for the full 7 days.
- C. No. Thrush is a self-limiting disorder, and nystatin is given for complete treatment.
- D. Yes. The medication should be refilled for a second week of therapy.
Correct Answer: B
Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection. Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush. Choice C is inaccurate as nystatin is not just for comfort but for effective treatment. Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.
A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter-sized blood spot on the dressing
- D. Pitting ankle edema
Correct Answer: A
Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.
The settings on a client's synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breaths/minute, tidal volume at 600 mL, FiO2 35%, and positive end-expiratory pressure (PEEP) 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse?
- A. Bilateral crackles in the lung bases.
- B. Low-pressure indicator alarm.
- C. Oxygen saturation of 91%.
- D. Respiratory rate of 18 breaths/minute.
Correct Answer: B
Rationale: A low-pressure alarm may indicate a disconnection or leak in the system, which needs immediate intervention. Bilateral crackles in the lung bases may indicate fluid overload but do not require immediate intervention in this case. An oxygen saturation of 91% is concerning but not as urgent as a potential equipment issue. A respiratory rate of 18 breaths/minute is higher than the set rate but may not necessitate immediate intervention unless accompanied by other distress symptoms.