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Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
- A. Preload
- B. Afterload
- C. Cardiac output
- D. All of the above
Correct Answer: D
Rationale: A multilumen pulmonary artery catheter, also known as a Swan-Ganz catheter, is used for advanced hemodynamic monitoring. It is inserted through a central line and positioned in the pulmonary artery to provide detailed information about various hemodynamic parameters including preload, afterload, and cardiac output.
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During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: A fixed nodular mass with dimpling of the overlying skin is the finding that most strongly suggests breast cancer. This presentation is concerning for an invasive carcinoma that has invaded into the surrounding tissues, leading to the dimpling of the skin. Breast cancer typically presents as a painless, hard, irregularly shaped, non-mobile mass. Dimpling of the skin overlying the mass is a sign of advanced disease and is often associated with a poor prognosis. Therefore, this finding should raise suspicion for breast cancer and prompt further evaluation and workup.
The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. What knowledge should the nurse's response should be based?
- A. Unacceptable because of the risk of sudden infant death syndrome (SIDS)
- B. Unacceptable because it does not encourage achievement of developmental milestones
- C. Acceptable to encourage fine motor development
- D. Acceptable to encourage head control and turning over
Correct Answer: D
Rationale: The correct knowledge that the nurse's response should be based on is that it is acceptable to encourage head control and turning over. At 3 months of age, encouraging the infant to be prone while awake can help promote the development of head control, neck strength, and eventually facilitate the ability to turn over. This practice is considered safe and beneficial for infants within the appropriate age range, as long as the infant is supervised during the awake period. It is important to promote safe sleep practices for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS), but allowing supervised tummy time for an awake infant is beneficial for their motor development.
A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy?
- A. Allow the child to choose what time to take her oral antibiotics.
- B. Allow the child to have a doll for medical play.
- C. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.
- D. Allow the child to watch age-appropriate videos.
Correct Answer: B
Rationale: Allowing preschoolers to participate in actions for which they are capable is an excellent way to enhance their sense of autonomy.
With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes?
- A. Hypernatremia
- B. Hyperchoremia
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: C
Rationale: Hypokalemia is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes. Potassium is an essential electrolyte for muscle function, including maintaining muscle tone and supporting proper nerve conduction for reflexes. When potassium levels are low, it can lead to muscle weakness, decreased muscle tone, and reduced deep tendon reflexes. With severe diarrhea, potassium is often lost along with fluids, leading to a potential electrolyte imbalance such as hypokalemia. Additionally, hypokalemia can cause cardiac arrhythmias, muscle cramps, and fatigue, further supporting the presence of this electrolyte imbalance in Ms. CC.
A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
- A. Deficient volume related to osmotic diuresis
- B. Decreased cardiac output related to elevated heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.