Nokea
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction. What tests should the nurse anticipate?
- A. Reticulocyte count, creatinine phosphokinase (CPK)
- B. Aspartate transaminase, alanine transaminase
- C. Sedimentation rate, WBC count
- D. Lactic dehydrogenase, CPK
Correct Answer: D
Rationale: Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
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A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.'
- B. A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'
- C. These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'
- D. This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'
Correct Answer: C
Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Increase the dosage by 2 mU/min increments at 15-minute intervals
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
- D. Question the order
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
- A. Encourage him to drink plenty of fluids
- B. Expect him to have nausea with vomiting
- C. Keep him awake for the next 12 hours
- D. Wake him up every 1-2 hours during the night
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
- A. Call the physician
- B. Assess her vital signs
- C. Give the prescribed oxytocic drug
- D. Massage her fundus
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Vitamin C and zinc
- B. Folic acid and niacin
- C. Vitamin A and biotin
- D. Thiamine and pyroxidine
Correct Answer: D
Rationale: Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.