Nokea
Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
- A. Low blood pressure
- B. Anxiety
- C. Headache
- D. Disorientation
Correct Answer: D
Rationale: Widening pulse pressure and aortic arch involvement in an aortic aneurysm suggest possible dissection affecting cerebral perfusion (e.g., carotid artery involvement), leading to disorientation or neurologic changes. Low blood pressure, anxiety, and headache are less specific or unrelated.
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Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
- A. Place the client's feet against a firm footboard.
- B. Reposition the client every 2 hours.
- C. Have the client wear ankle-high tennis shoes at intervals throughout the day.
- D. Massage the client's feet and ankles regularly.
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?
- A. High oxygen concentrations will cause coughing and dyspnea.
- B. High oxygen concentrations may inhibit the hypoxic stimulus to breathe.
- C. Increased oxygen use will cause the client to become dependent on the oxygen.
- D. Administration of oxygen is contraindicated in clients who are using bronchodilators.
Correct Answer: B
Rationale: In COPD, high oxygen concentrations may suppress the hypoxic drive to breathe, risking CO2 retention. Oxygen does not cause coughing, dependency, or contraindication with bronchodilators.
What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
As a result of a gastric resection, the client is at risk for development of dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes?
- A. Excess secretion of digestive enzymes in the intestines.
- B. Rapid emptying of stomach contents into the small intestine.
- C. Excess glycogen production by the liver.
- D. Loss of gastric enzymes.
Correct Answer: B
Rationale: Dumping syndrome occurs due to rapid emptying of stomach contents into the small intestine, causing osmotic and vasomotor symptoms. The other options are not primary causes.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.