Nokea
A client has just undergone an upper gastrointestinal (GI) series. Upon the client's return to the unit, what primary health care provider's prescriptions does the nurse expect to note as a part of routine postprocedure care?
- A. Bland diet
- B. NPO status
- C. Mild laxative
- D. Decreased fluids
Correct Answer: C
Rationale: Barium sulfate, which is used as a contrast material during an upper GI series, is constipating. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or cathartics are administered as part of routine postprocedure care. Increased (not decreased) fluids are also helpful but do not act in the same way as a laxative to eliminate the barium.
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The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
- A. Begin administering supplemental oxygen.
- B. Document the findings according to facility policies.
- C. Notify the child's primary health care provider immediately.
- D. Reassess the respiratory rate, rhythm, and depth in 15 minutes.
Correct Answer: B
Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.
A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?
- A. Cover the client with warm blankets.
- B. Minimize visual and auditory stimuli present.
- C. Elevate the client's head to at least 45 degrees.
- D. Administer oxygen at 4 L per minute by nasal cannula.
Correct Answer: C
Rationale: Excess fluid volume can lead to symptoms such as shortness of breath and cerebral edema, which can be alleviated by elevating the head of the bed to at least 45 degrees to promote venous drainage and reduce intracranial pressure. This is a safe and effective nursing intervention to increase comfort until specific medical therapy is prescribed.
The client states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
- A. Orthopnea
- B. Dyspnea at rest
- C. Dyspnea on exertion
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a 'three-point' position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.
- A. Yellowish sclera
- B. Reports of severe fatigue
- C. Pink mucous membranes
- D. Increased vaginal secretions
- E. Reports of frequent headaches
- F. Reports of increased frequency of voiding
Correct Answer: B,E
Rationale: Iron deficiency anemia is described as a hemoglobin blood concentration of less than 10.5 to 11.0 g/dL (105 to 110 mmol/L). Complaints of headaches and severe fatigue are abnormal findings and may reflect complications of this type of anemia caused by the decreased oxygen supply to vital organs. Options 3, 4, and 6 are normal findings in the first trimester of pregnancy. Yellow sclera (whites of the eyes) is associated with jaundice.