Nokea
A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
- A. Palpate the pedal pulses.
- B. Measure the abdominal girth.
- C. Assess the client about the level of pain in the area.
- D. Auscultate over the iliac area with a Doppler device.
Correct Answer: B
Rationale: Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected.
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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.
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention should the nurse include in the plan of care to assist in maintaining the comfort of this client?
- A. Monitoring for bloody sputum
- B. Evaluating arterial blood gas results
- C. Keeping the head of the bed elevated
- D. Assessing respiratory rate, rhythm, depth, and breath sounds
Correct Answer: C
Rationale: Clients with respiratory difficulties are often more comfortable with the head of the bed elevated. Options 1, 2, and 4 are appropriate measures to evaluate respiratory function and avoid complications. Option 3 is the only choice that addresses planning for client comfort.
While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse should determine that the client is taking the medication to treat which disorder?
- A. Glaucoma
- B. Pyloric stenosis
- C. Renal insufficiency
- D. Urinary frequency and urgency
Correct Answer: D
Rationale: Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
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.
What is the smallest gauge catheter that the nurse can use to administer blood?
- A. 12 gauge
- B. 20 gauge
- C. 22 gauge
- D. 24 gauge
Correct Answer: B
Rationale: An intravenous catheter used to infuse blood should be at least 20 gauge or larger to help prevent additional hemolysis of red blood cells and to allow infusion of the blood without occluding the IV catheter.