Nokea
A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
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When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
- A. Equal bilateral chest expansion
- B. Respiratory rate of 22 breaths per minute
- C. Diminished breath sounds on the affected side
- D. Few scattered wheezes, unchanged from baseline
Correct Answer: C
Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.
The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
- A. Covering the back dressing with a binder
- B. Placing the infant in a head-down position
- C. Strapping the infant in a baby seat sitting up
- D. Elevating the head with the infant in the prone position
Correct Answer: D
Rationale: Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial side-lying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity.
The nurse is caring for a client prescribed digoxin. Which manifestations correlate with a digoxin level of 2.3 ng/dL (2.93 nmol/L)? Select all that apply.
- A. Nausea
- B. Drowsiness
- C. Photophobia
- D. Increased appetite
- E. Increased energy level
- F. Seeing halos around bright objects
Correct Answer: A,B,C,F
Rationale: Digoxin is a cardiac glycoside used to manage and treat heart failure, control ventricular rate in clients with atrial fibrillation, and treat and prevent recurrent paroxysmal atrial tachycardia. The therapeutic range is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). Signs of toxicity include gastrointestinal disturbances, including anorexia, nausea, and vomiting; neurological abnormalities such as fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares; facial pain; personality changes; and ocular disturbances such as photophobia, halos around bright lights, and yellow or green color perception.