Nokea
A goal for a postpartum client states, 'The client will remain free of infection during her hospital stay.' Which assessment data would support that the goal has been met?
- A. Normal appetite
- B. Absence of fever
- C. Minimal vaginal bleeding
- D. Moderate breast tenderness
Correct Answer: B
Rationale: Fever is the first indication of an infection. Therefore, the absence of a fever indicates that an infection is not present. The remaining options are not associated with a postpartum infection.
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The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
- A. I am in control of myself now.
- B. I need to use the restroom right away.
- C. I'd like to go back to my room and be alone for a while.
- D. I can't breathe in here. It feels like the walls are closing in on me.
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.
A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?
- A. Weight loss
- B. Resolution of infection
- C. Decreased blood glucose
- D. Decreased blood pressure
Correct Answer: C
Rationale: Glipizide is an oral hypoglycemic agent that is taken in the morning. It is not used to enhance weight loss, treat infection, or decrease blood pressure.
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met?
- A. 3 mcg/mL (11.9 mcmol/L)
- B. 8 mcg/mL (31.7 mcmol/L)
- C. 15 mcg/mL (59.5 mcmol/L)
- D. 24 mcg/mL (95.2 mcmol/L)
Correct Answer: C
Rationale: The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication.
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
- A. Elevate the head of the bed.
- B. Provide oxygen during stressful periods.
- C. Limit the time that the infant is allowed to bottle-feed.
- D. Wake the infant for feedings to ensure adequate nutrition.
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.