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After a 26-year-old gravida 4, para 0 experienced a spontaneous abortion at 9 weeks gestation, how should the nurse intervene after observing the client crying softly one hour post dilation and curettage (D&C)?
- A. Offer to call the social worker to discuss the possibility of adoption
- B. Reassure the client that the infertility specialist can help
- C. Express sorrow for the client's grief and offer to sit with her
- D. Chart the vital signs and amount of vaginal bleeding
Correct Answer: C
Rationale: After a traumatic experience like a spontaneous abortion, it is crucial for the nurse to provide emotional support. Expressing sorrow for the client's grief and offering to sit with her demonstrates empathy and allows the client to process her emotions. Options A and B focus on future possibilities and medical interventions, which may not be immediately appropriate. Option D, while important for monitoring the client's physical status, does not address the client's emotional needs at that moment.
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Which client is at the highest risk for developing pressure ulcers?
- A. A 50-year-old client with a fractured femur
- B. A 30-year-old client with diabetes mellitus
- C. A 65-year-old client with limited mobility
- D. A 70-year-old client with a history of stroke
Correct Answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?
- A. Moon face, slow wound healing, muscle wasting, sodium and water retention
- B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
- C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
- D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
Correct Answer: A
Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.
When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?
- A. Slightly above the level of the heart
- B. At the level of the heart
- C. At a level of comfort for the client
- D. Below the level of the heart
Correct Answer: B
Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.
After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
- A. Remove the catheter and apply direct pressure for 5 minutes.
- B. Initiate intravenous fluids as prescribed.
- C. Secure the catheter using aseptic technique.
- D. Notify the healthcare provider of the need to reposition the catheter.
Correct Answer: B
Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.
The healthcare provider is providing discharge instructions to a client with chronic heart failure. Which dietary recommendation is most appropriate?
- A. Increase fluid intake.
- B. Follow a low-sodium diet.
- C. Follow a high-protein diet.
- D. Increase sodium intake.
Correct Answer: B
Rationale: The most appropriate dietary recommendation for a client with chronic heart failure is to follow a low-sodium diet. This helps manage the condition by reducing fluid retention and the workload on the heart. High fluid intake can lead to fluid overload and exacerbate heart failure symptoms. While protein is important for overall health, a high-protein diet is not specifically indicated for chronic heart failure. Increasing sodium intake is contraindicated in heart failure as it can worsen fluid retention and increase the workload on the heart.