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Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: Left ventricular end-diastolic pressure. The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure, assessing the heart's ability to pump effectively.
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The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
- A. Although the results are here, your doctor will explain them later.
- B. Your child has fewer red blood cells that carry oxygen.
- C. The blood cells that carry nutrients to the cells are too large.
- D. There are not enough blood cells in your child's circulation.
Correct Answer: B
Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
An adult is admitted to the emergency department following a fall. A piece of bone is protruding through the skin of the left thigh. In addition to assessing vital signs, what information is most essential to obtain from the client at this time?
- A. History of previous falls and fractures
- B. Date of last tetanus shot
- C. Type of environment where the fall took place
- D. Any previous surgeries
Correct Answer: B
Rationale: An open fracture (bone protruding) risks tetanus infection; knowing the last tetanus shot date is critical to determine prophylaxis need. Fall history, environment, or surgeries are secondary.
A nurse is reinforcing fall-prevention teaching to the spouse of a 78-year-old client who recently experienced a stroke. What suggestion by the nurse is most effective in preventing falls?
- A. Ensure that your spouse rises slowly after sitting or lying down.'
- B. Purchase a walker for your spouse to use when walking around the home'
- C. Remove all area rugs and install grab bars in the bathroom'
- D. Schedule a home health aide to monitor your spouse while you are away.'
Correct Answer: C
Rationale: Removing rugs and installing grab bars (C) directly addresses environmental hazards, the most effective fall prevention strategy. Rising slowly (A), using a walker (B), or hiring an aide (D) are helpful but less comprehensive.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.