Nokea
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
- A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode
- B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
- C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
- D. Using distraction to help control the client's hyperventilation episodes
Correct Answer: C
Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.
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A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?
- A. Steamed broccoli
- B. Wheat toast
- C. Chocolate chip cookie
- D. Bran cereal
Correct Answer: A
Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (B), chocolate chip cookies (C), and bran cereal (D) contain gluten.
The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:
- A. Position the client flat in bed
- B. Administer eye drops as ordered
- C. Restrict fluids before surgery
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Keep the umbilical area moist with Vaseline until the stump falls off.
- B. Keep the umbilical area covered at all times with the diaper.
- C. Clean the umbilical cord with alcohol at each diaper change.
- D. Clean the umbilical cord daily with soap and water during the bath.
Correct Answer: C
Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.