Nokea
A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding should the nurse most likely expect to note?
- A. Increased urine output
- B. Increased blood pressure
- C. Decreased fetal heart rate
- D. Decreased brachial reflexes
Correct Answer: B
Rationale: The major manifestation of gestational hypertension is increased blood pressure. As the disease progresses, it is possible that increased brachial reflexes, decreased fetal heart rate and variability, and decreased urine output will occur, particularly during labor.
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The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites?
- A. Loose but intact pin sites
- B. Clear drainage from the pin sites
- C. Purulent drainage from the pin sites
- D. Redness and swelling around the pin sites
Correct Answer: B
Rationale: A small amount of clear drainage ('weeping') may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock?
- A. Reflexes
- B. Pulse rate
- C. Temperature
- D. Blood pressure
Correct Answer: A
Rationale: Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery.
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse should assess for which expected but adverse effect of PEEP?
- A. Decreased peak pressure on the ventilator
- B. Increased rectal temperature from 98°F to 100°F
- C. Decreased heart rate from 78 to 64 beats per minute
- D. Systolic blood pressure decrease from 122 to 98 mm Hg
Correct Answer: D
Rationale: PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.