Nokea
A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats per minute (BPM), and respirations (R) 20 breaths per minute. The nurse administers nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data?
- A. BP 150/90 mm Hg, P 70 BPM, R 24 breaths per minute
- B. BP 100/60 mm Hg, P 96 BPM, R 20 breaths per minute
- C. BP 100/60 mm Hg, P 70 BPM, R 24 breaths per minute
- D. BP 160/100 mm Hg, P 120 BPM, R 16 breaths per minute
Correct Answer: B
Rationale: Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the blood pressure to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta blockers, such as propranolol, are often used in conjunction with nitroglycerin to prevent this rise in heart rate. If chest pain is reduced and cardiac workload is reduced, the client will be more comfortable; therefore, a rise in respirations should not be seen.
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Which conditions place the client receiving enteral nutrition at increased risk for aspiration? Select all that apply.
- A. Sedation
- B. Coughing
- C. An artificial airway
- D. Head-elevated position
- E. Nasotracheal suctioning
- F. Decreased level of consciousness
Correct Answer: A,B,C,E,F
Rationale: A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Some common conditions that increase the risk of aspiration include sedation, coughing, an artificial airway, nasotracheal suctioning, decreased level of consciousness, and lying flat. A head-elevated position does not increase the risk of aspiration.
The nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. What action should the nurse take?
- A. Return the bag to the blood bank.
- B. Infuse the blood using filter tubing.
- C. Add 10 mL normal saline to the bag.
- D. Agitate the bag to mix contents gently.
Correct Answer: A
Rationale: The nurse should return the unit of blood to the blood bank because the gas bubbles in the bag indicate possible contamination. Whenever administering blood, the nurse would use filter tubing to trap particulate matter. Although normal saline can be infused concurrently with the blood, normal saline or any other substance should never be added to the blood in a blood bag. The bag should not be agitated because this can harm red blood cells.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.