Nokea
A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.
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The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?
- A. Hemorrhoids
- B. Postterm labor
- C. Maternal anemia
- D. Costovertebral angle tenderness
Correct Answer: C
Rationale: Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses. Options 1 and 4 occur in a twin pregnancy but would not be as high a priority as anemia. Option 2 is incorrect because twin pregnancies often end in prematurity.
The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
- A. Dull and aching pain in the costovertebral area
- B. Aching and cramplike pain throughout the abdomen
- C. Pain that is sharp and radiating posteriorly to the spinal column
- D. Pain that is excruciating, wavelike, and radiating toward the genitalia
Correct Answer: D
Rationale: The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of the stone's abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a dull ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.