Nokea
A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury?
- A. Obtaining a chest x-ray
- B. Assessing blood pressure and pulse
- C. Obtaining a complete blood cell count and liver function studies
- D. Scheduling a drug level to be drawn 1 hour after the dose is administered
Correct Answer: B
Rationale: Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.
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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 performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
- A. Peeling of the skin
- B. Smooth soles without creases
- C. Lanugo covering the entire body
- D. Vernix that covers the body in a thick layer
Correct Answer: A
Rationale: The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo covering the entire body, and thick vernix covering the body.
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.
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
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.