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A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds?
- A. Absent
- B. Vesicular
- C. Bronchial
- D. Bronchovesicular
Correct Answer: C
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.
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The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse should instruct the parents to take which measure?
- A. Restrict corn and rice in the diet.
- B. Restrict fresh vegetables in the diet.
- C. Substitute grain cereals with pasta products.
- D. Avoid foods that are hidden sources of gluten.
Correct Answer: D
Rationale: Gluten is found primarily in the grains of wheat, rye, barley, and oats. Gluten is added to many foods as hydrolyzed vegetable protein that is derived from cereal grains; therefore, labels need to be read. Corn and rice, as well as vegetables, are acceptable in a gluten-free diet, and corn and rice become substitute foods. Many pasta products contain gluten.
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.
A child sustains a greenstick fracture of the humerus from a fall out of a tree house. The nurse describes this type of fracture to the parents and should provide them with which picture? Refer to figures 1 to 4.
- A. fracture_1.PNG
- B. fracture_2.PNG
- C. fracture_3.PNG
- D. fracture_4.PNG
Correct Answer: A
Rationale: A greenstick fracture is an incomplete fracture where the bone bends and breaks on one side without breaking completely through, common in children due to their flexible bones. The nurse should select the picture that depicts this type of fracture, typically showing a bend with a partial break on one side of the bone. This distinguishes it from complete fractures or other types like comminuted or spiral fractures.
The home care nurse is making a follow-up visit to a client after receiving a renal transplant. Which assessment data support the possible existence of acute graft rejection? Select all that apply.
- A. Pale skin color
- B. Urine output of 45 mL/hour
- C. Blood pressure of 164/98 mm Hg
- D. Temperature of 102.4°F (39.1°C)
- E. Client reporting 'feeling so very tired'
- F. Client reporting that graft site is tender when touched
Correct Answer: C,D,E,F
Rationale: Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years after transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is immediately begun with corticosteroids and possibly also with monoclonal antibodies and antilymphocytic agents. None of the other options present symptomology associated with acute graft rejection.