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A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
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The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?
- A. Placing the infant under phototherapy
- B. Keeping the infant NPO until the second period of reactivity
- C. Encouraging the mother to breast-feed the infant every 2 to 3 hours
- D. Encouraging the mother to supplement breast-feeding with formula
Correct Answer: C
Rationale: To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium. Breast-feeding should begin as soon as possible after birth while the infant is in the first period of reactivity.
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.
The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing?
- A. Apply a Kerlix roll and tape it to the skin.
- B. Apply a large, soft pad and tape it to the skin.
- C. Apply small Montgomery straps and tie the edges together.
- D. Apply a Kling roll and tape the edge of the roll onto the bandage.
Correct Answer: D
Rationale: Standard dressing technique includes the use of Kling rolls on circumferential dressings. With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps should not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway).
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 is caring for a client who is receiving total parenteral nutrition and has a prescription for an intravenous intralipid infusion. What intervention should the nurse implement before hanging the intralipid infusion?
- A. Refrigerate the bottle of solution.
- B. Add 100 mL normal saline to the infusion bottle.
- C. Place an in-line filter on the administration tubing.
- D. Check the solution for separation or an oily residue.
Correct Answer: D
Rationale: Intralipids provide nonprotein calories and prevent or correct fatty acid deficiency. The nurse checks the solution for separation or an oily appearance because this can indicate a spoiled or contaminated solution. Refrigeration renders the intralipid solution too thick to administer. Because they can affect the stability of the solution, the nurse avoids injecting additives into the intralipid infusion. Furthermore, an in-line filter is not used because it can disrupt the flow of solution by becoming clogged.