Nokea
A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this anemia is a result of:
- A. Mother's increased blood volume
- B. Mother's decreased blood volume
- C. Fetal blood volume increase
- D. Increase in iron absorption
Correct Answer: A
Rationale: Increased maternal blood volume in the first trimester causes dilutional anemia due to a relative decrease in red blood cell concentration.
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A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
- A. It is determined that he has no signs of wound infection
- B. He is able to eat a full meal without evidence of nausea or vomiting
- C. The nurse can detect bowel sounds in all four quadrants
- D. His blood pressure returns to its preoperative baseline level or greater
Correct Answer: C
Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Correct Answer: C
Rationale: Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. The side effects of morphine sulfate include respiratory depression. Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
A 60-year-old woman exhibits forgetfulness, emotional lability, confusion, and decreased concentration. She has been unable to perform activities of daily living without assistance. After a thorough medical evaluation, a diagnosis of Alzheimer's disease was made. An appropriate nursing intervention to decrease the anxiety of this client would include:
- A. Allowing the client to perform activities of daily living as much as possible unassisted
- B. Confronting confabulations
- C. Reality testing
- D. Providing a highly stimulating environment
Correct Answer: A
Rationale: This answer is correct. The more the client is able to control her daily routine, the less anxiety she will experience. This answer is incorrect. Confrontation tends to increase anxiety. This answer is incorrect. Reality testing is an assessment tool. It does not decrease anxiety. This answer is incorrect. A highly stimulating environment increases distractibility and anxiety.
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
- A. The blood pressure
- B. The temperature
- C. The urinary output
- D. The specific gravity of the urine
Correct Answer: A
Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate medical attention.