Nokea
A nurse is assisting a pregnant client who is having an amniocentesis.
Which of the following statements by the nurse indicates the correct
teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid
from the sac around the fetus during pregnancy. It may be analyzed for
certain disorders or complications associated with pregnancy.
Following the procedure, the nurse should wash the client's abdomen
and place a small bandage over the puncture site
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Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.
Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
- A. Variable decelerations
- B. Late decelerations
- C. Early decelerations
- D. Accelerations
Correct Answer: B
Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
A client has started sweating profusely due to intense heat. His overall
luid volume is low and he has developed electrolyte imbalance. This
client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough
diaphoresis that he becomes dehydrated. Intense sweating can cause
both luid and electrolyte imbalances. Untreated heat exhaustion can
lead to heat stroke, which results in organ damage, loss of
consciousness, or death.
Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
- A. The test determines if the client is anemic and needs iron supplements
- B. The test determines if there is excess glucose building up in the urine
- C. The test determines the amount of hemoglobin reaching the liver to support gluconeogenesis
- D. The test determines the amount of hemoglobin that is coated with glucose
Correct Answer: D
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time. Choices A, B, and C are incorrect. Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test. Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test. Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.