Nokea
A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. Which expected prescription should the nurse immediately implement for this client? Select all that apply.
- A. Supplemental oxygen
- B. High Fowler's position
- C. Semi-Fowler's position
- D. Morphine sulfate intravenously
- E. Two tablets of acetaminophen with codeine
- F. Meperidine hydrochloride intravenously
Correct Answer: A,C,D
Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
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The nurse caring for an infant demonstrating diarrhea should monitor the infant for which early sign of dehydration?
- A. Cool extremities
- B. Gray, mottled skin
- C. Capillary refill of 3 seconds
- D. Apical pulse rate of 200 beats per minute
Correct Answer: D
Rationale: Dehydration causes interstitial fluid to shift to the vascular compartment in an attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory failure occurs. The blood pressure will decrease and the pulse rate will increase. This will be followed by peripheral symptoms.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.
The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated?
- A. Strip the tubing and assess for a blood return.
- B. Check the regional tissue for redness and warmth.
- C. Increase the infusion rate and observe for swelling.
- D. Gently palpate regional tissue for edema and coolness.
Correct Answer: D
Rationale: When assessing an IV for clinical indicators of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the surrounding tissues, which can increase the risk of tissue damage. Redness and warmth are more likely to indicate infection or phlebitis.
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury?
- A. Hypothermia blanket
- B. Emergency tracheostomy kit
- C. Magnesium sulfate in a ready-to-inject vial
- D. Ampule of saturated solution of potassium iodide
Correct Answer: B
Rationale: Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state.