Nokea
A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication?
- A. Infuse over 1 hour and allow the client to ambulate.
- B. Infuse over 1 hour with the client in a supine position.
- C. Administer over 30 minutes with the client in a reclining position.
- D. Administer by IV push over 15 minutes with the client in a supine position.
Correct Answer: B
Rationale: IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position.
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The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
- A. Breathes in and then holds the breath for 30 seconds
- B. Loosens the abdominal muscles while breathing out
- C. Inhales with puckered lips and exhales with the mouth open wide
- D. Breathes so that expiration is two to three times as long as inspiration
Correct Answer: D
Rationale: COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.
The nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks' gestation. In what position should the nurse place the client to perform the procedure?
- A. In a standing position
- B. In the Trendelenburg position
- C. Supine with the head of the bed elevated to 45 degrees
- D. Supine with her head on a pillow and knees slightly flexed
Correct Answer: D
Rationale: When measuring fundal height, the client lies in a supine (back) position with her head on a pillow and knees slightly flexed. The standing position, Trendelenburg (head lowered), or supine with the head of the bed elevated to 45 degrees would prevent the nurse from getting an accurate measurement.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?
- A. Waves of loud gurgles auscultated in all four quadrants
- B. Soft gurgling or clicking sounds auscultated in all four quadrants
- C. Low-pitched swishing sounds auscultated in one or two quadrants
- D. Very high-pitched loud rushes auscultated, especially in one or two quadrants
Correct Answer: B
Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction.
An adolescent is hospitalized with a diagnosis of Rocky Mountain spotted fever (RMSF). The nurse anticipates that which medication will be prescribed?
- A. Ganciclovir
- B. Amantadine
- C. Doxycycline
- D. Amphotericin B
Correct Answer: C
Rationale: The nursing care of an adolescent with RMSF includes the administration of doxycycline. An alternative medication is chloramphenicol. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat Parkinson's disease. Amphotericin B is used for fungal infections.
The nurse is ambulating a client for the first time after having abdominal surgery. What clinical manifestations should indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply.
- A. Nausea
- B. Dizziness
- C. Bradycardia
- D. Lightheadedness
- E. Flushing of the face
- F. Reports of seeing spots
Correct Answer: A,B,D,F
Rationale: Orthostatic hypotension occurs when a normotensive person develops symptoms of low blood pressure when rising to an upright position. Whenever the nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension. Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result without intervention, which includes immediately assisting the client to a lying position.