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A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Meconium aspiration syndrome
- D. Transient tachypnea of the newborn
Correct Answer: C
Rationale: Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome (MAS). MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. The symptoms noted in the question are unrelated to hypoglycemia. Respiratory distress syndrome is a complication of preterm infants. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section.
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The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?
- A. An insignificant finding
- B. An improvement in condition
- C. Decreasing intracranial pressure
- D. Deteriorating neurological function
Correct Answer: D
Rationale: The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Options 1, 2, and 3 are inaccurate interpretations.
A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.
The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?
- A. Ask the client to walk and observe the gait.
- B. Lightly massage the calf area to relieve the pain.
- C. Check the calf area for temperature, color, and size.
- D. Administer PRN morphine sulfate as prescribed for postoperative pain.
Correct Answer: C
Rationale: The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.