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A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice. The nurse's response is based on the knowledge that:
- A. The symptoms could easily have been caused by constipation, which an enema would relieve
- B. Heat would help to relax the abdominal muscles and relieve her pain
- C. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
- D. Complaints of stomach ache are common in young children and are generally best ignored
Correct Answer: C
Rationale: Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation, especially with fever and vomiting.
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A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 5-1/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
- A. Provide food and fluids at the client's request
- B. Maintain IV, increasing the rate hourly until the client voids
- C. Report to the surgeon if the client is unable to void within 8 hours of surgery
- D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
Correct Answer: C
Rationale: Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?
- A. The fundus is firm and three finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus three finger widths below the umbilicus by day three postpartum indicates normal uterine involution, as the uterus contracts and descends.
A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:
- A. Abnormal development of the embryo
- B. A distended or ruptured fallopian tube
- C. A congenital abnormality of the tube
- D. A malfunctioning of the placenta
Correct Answer: B
Rationale: The embryo itself may develop normally in the first several weeks of an ectopic pregnancy. An ectopic pregnancy in the fallopian tube causes severe pain owing to the size of the growing embryo within the narrow lumen of the tube, causing distention and finally rupture within the first 12 weeks of pregnancy. The Fallopian tube may either be normal or contain adhesions caused by a history of pelvic inflammatory disease or tubal surgeries, neither of which are congenital causes. An ectopic pregnancy does not involve a dysfunctional placenta, but the implantation of the blastocyst outside the uterus.