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Following a CVA, the nurse assesses that a client developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
- A. Continuous tube feeding at 65 ml/hr via gastrostomy.
- B. Total parenteral nutrition to be infused at 125 ml/hour.
- C. Nasogastric tube connected to low intermittent suction.
- D. Metoclopramide (Reglan) intermittent piggyback.
Correct Answer: A
Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. Dysphagia, hypoactive bowel sounds, and a distended abdomen indicate a potential risk for aspiration or impaired gastrointestinal motility. Continuous tube feeding may worsen these conditions. The nurse should question this prescription to prevent further complications. Choices B, C, and D are not immediate concerns for dysphagia and bowel issues. Total parenteral nutrition, nasogastric tube connected to suction, and metoclopramide can be appropriate interventions for nutritional support and bowel motility in this scenario.
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What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Soft, spongy fundus.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 BPM.
- D. Unilateral lower leg pain.
Correct Answer: C
Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult.
A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony.
B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage.
D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.
A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
- A. Refuses to eat her favorite meals at home.
- B. Drinks more soft drinks than previously.
- C. Voids only one or two times per day.
- D. Gained 10 pounds within one month.
Correct Answer: B
Rationale: The correct answer is B because increased thirst and drinking more fluids than usual is a common symptom of diabetes mellitus due to high blood sugar levels causing dehydration. Refusing to eat favorite meals (choice A) is not a typical symptom. Voids only one or two times per day (choice C) is more related to urinary issues than diabetes. Gaining 10 pounds within one month (choice D) is not a specific symptom of diabetes and can be attributed to various factors.
A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?
- A. Strict control of blood glucose levels.
- B. Regular dressing changes with sterile technique.
- C. Application of antibiotic ointment.
- D. Hydrotherapy treatment daily.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients.
2. High blood glucose levels can impair wound healing by affecting circulation and immune response.
3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications.
4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels.
5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention.
6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.
A client who underwent a total hip replacement is receiving discharge teaching from a nurse. Which instruction should the nurse include?
- A. Avoid crossing your legs at the knees.
- B. Sit only in low chairs for comfort.
- C. Bend at the waist to pick up objects.
- D. Sleep on the affected side to prevent discomfort.
Correct Answer: A
Rationale: The correct answer is A: Avoid crossing your legs at the knees. Crossing legs increases risk of dislocation post hip replacement. It maintains proper alignment and reduces strain on the hip joint. Sitting in low chairs (B) can strain the hip. Bending at the waist (C) can strain the hip joint. Sleeping on the affected side (D) can lead to discomfort and pressure on the hip joint.
The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Hypokalemia can exacerbate cardiac arrhythmias in patients with heart failure. Monitoring serum potassium levels is crucial to prevent complications.
Incorrect choices:
A: Serum sodium - Furosemide may cause hyponatremia, but it is less critical compared to hypokalemia in a client with heart failure.
C: Serum calcium - Furosemide does not directly affect calcium levels significantly in most cases.
D: Serum magnesium - While furosemide can cause hypomagnesemia, monitoring potassium is more essential in this scenario due to its impact on cardiac function.