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A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect?
- A. Memory loss and disorientation
- B. Numbness in the face, mouth, and tongue
- C. Radial pulse differences over 10 bpm
- D. Frontal headache with associated nausea or emesis
Correct Answer: C
Rationale: Subclavian artery obstruction can cause reduced blood flow to the arm, leading to radial pulse differences between arms, a hallmark of conditions like subclavian steal syndrome.
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A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. confused with cold, clammy skin and a pulse of 110.
- B. lethargic with hot, dry skin and rapid, deep respirations.
- C. alert and cooperative with a BP of 130/80 and respirations of 12.
- D. short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.
- A. Scheduled toileting
- B. Stool softeners
- C. High-fiber diet
- D. Daily laxatives
- E. Periodic enemas
- F. Routine exercise
Correct Answer: A,B,C,F
Rationale: Bowel training includes scheduled toileting (A), stool softeners (B), high-fiber diet (C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (D) and periodic enemas (E) are not preferred long-term.
A client is receiving enteral feedings through a nasogastric tube, and the nurse is administering the client's medications. Which of the following can be administered through the NG tube? Select all that apply.
- A. Hard extended-release capsules (opened, crushed, and dissolved)
- B. Pills (crushed and dissolved)
- C. Enteric-coated tablets (crushed and dissolved)
- D. Liquid suspension
- E. Soft-gel capsules (dissolved)
- F. Sublingual wafer (dissolved)
Correct Answer: B,D
Rationale: Pills (crushed, dissolved) (B) and liquid suspension (D) are safe for NG administration. Extended-release (A) and enteric-coated (C) medications should not be crushed; soft-gel (E) and sublingual (F) are not suitable.
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.