Nokea
A client is transferred to the intensive care unit following a conornary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?
- A. Urine output of 50 ml in the past hour
- B. Temperature of 99°F
- C. Strong pedal pulses bilaterally
- D. Central venous pressure 15 mmHâ‚‚O
Correct Answer: D
Rationale: A central venous pressure of 15 mmHâ‚‚O is elevated, indicating potential fluid overload or cardiac issues, requiring reporting.
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A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge promotes knee extension, helping to prevent or reduce flexion contractures in rheumatoid arthritis.
A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.
The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).
A 14-year-old client has been diagnosed with celiac disease after a long history of diarrhea, anemia, and weight loss. What type of diet does the nurse anticipate the client will require?
- A. High protein
- B. Dairy free
- C. Low carbohydrate
- D. Gluten free
Correct Answer: D
Rationale: Celiac disease requires a gluten-free diet (D) to prevent intestinal damage. Other diets (A, B, C) are not specific to celiac.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- A. Magnesium sulfate
- B. Calcium gluconate
- C. Dinoprostone (Prostin E.)
- D. Bromocrystine (Parlodel)
Correct Answer: C
Rationale: Dinoprostone is used to induce uterine contractions and facilitate expulsion in a missed abortion.