Nokea
Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?
- A. Prevent the influx of calcium into cells.
- B. Restore a normal blood pressure reading.
- C. Prevent the inflammatory process.
- D. Dissolve the clot that has formed.
Correct Answer: A
Rationale: Nimodipine, a calcium channel blocker, prevents calcium influx into cells, reducing vasospasm post-aneurysm rupture. It doesn’t normalize BP (B), prevent inflammation (C), or dissolve clots (D).
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A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:
- A. Housework phobia
- B. Malingering
- C. Conversion reaction
- D. Agoraphobia
Correct Answer: C
Rationale: A conversion reaction is a physical expression of an emotional conflict with no organic basis, such as paralysis in this case.
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
- A. 50-100 mL
- B. 200-300 mL
- C. 300-500 mL
- D. 1000-1200 mL
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The client aspirated tube feeding.
- B. The nurse has placed the suction catheter in the esophagus.
- C. This is a normal finding.
- D. The feeding is infusing into the trachea.
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. Would you describe the intensity, duration, and symptoms associated with your pain?
- B. Do you experience swelling at the end of the day in the affected and unaffected leg?
- C. Have you had any lesions of the affected leg that have been difficult to heal?
- D. Do your muscle spasms occur following rest, walking, or exercising?
Correct Answer: D
Rationale: Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.
The nurse is caring for a client in labor. The fetal heart rate is 80 bpm with moderate variability. The most appropriate initial action by the nurse is to:
- A. Notify the physician
- B. Administer oxygen at 8-10 liters per minute
- C. Reposition the client to her left side
- D. Increase the IV fluid rate
Correct Answer: C
Rationale: A fetal heart rate of 80 bpm indicates bradycardia possibly due to cord compression or uteroplacental insufficiency. Repositioning the client to her left side improves placental perfusion and is the first action. Oxygen notifying the physician or increasing fluids are secondary.