Nokea
Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?
- A. Administer hypotonic solutions
- B. Keep the head of the bed elevated
- C. Increase the client's core body temperature to 99.9 degrees
- D. Administer corticosteroids as ordered
Correct Answer: D
Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.
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Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
- A. The test determines if the client is anemic and needs iron supplements
- B. The test determines if there is excess glucose building up in the urine
- C. The test determines the amount of hemoglobin reaching the liver to support gluconeogenesis
- D. The test determines the amount of hemoglobin that is coated with glucose
Correct Answer: D
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time. Choices A, B, and C are incorrect. Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test. Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test. Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
- A. Place the client in the Trendelenburg position
- B. Contact the physician for an order for antibiotics
- C. Administer oxygen therapy
- D. Decrease his IV rate
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.
When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
- A. A normal reading
- B. An abnormally low reading
- C. An abnormally high reading
- D. A fluctuating reading
Correct Answer: B
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?
- A. Variable decelerations
- B. Late decelerations
- C. Early decelerations
- D. Accelerations
Correct Answer: B
Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.
Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct Answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.