Nokea
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When should the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
- A. During dialysis
- B. Just before dialysis
- C. The day after dialysis
- D. Upon return from dialysis
Correct Answer: D
Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.
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A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.
The nurse determines that a client understands the purpose of a phytonadione injection for her newborn when she is heard making which statement to the baby's father?
- A. The baby's liver cannot produce that vitamin.
- B. Most newborns need a supplement of this vitamin.
- C. All newborns lack intestinal bacteria to produce this vitamin.
- D. It's unusual but our baby lack's the vitamin that helps the blood to clot.
Correct Answer: C
Rationale: The absence of normal flora needed to synthesize vitamin K (phytonadione) in the normal newborn gut results in low levels of vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. An injection is administered prophylactically on the day of birth to combat the deficiency.
A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
- A. 5%
- B. 10%
- C. 15%
- D. 25%
Correct Answer: A
Rationale: Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%. Normal carboxyhemoglobin (HbCO) levels are 0% to 3% for nonsmokers and 3% to 8% for smokers. Levels of 10% to 20% cause headaches, nausea, vomiting, and dyspnea. Levels of 30% to 40% cause severe headaches, syncope, and tachydysrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Options 2, 3, and 4 are elevated levels.
A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?
- A. Monitor the fetal heart rate.
- B. Notify the primary health care provider.
- C. Transfer the client to the delivery room.
- D. Place the client in the Trendelenburg position.
Correct Answer: D
Rationale: On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client in the Trendelenburg position while gently holding the presenting part upward to relieve the cord compression. This position is maintained and the primary health care provider is notified. The fetal heart rate also needs to be monitored to assess for fetal distress. The client is transferred to the delivery room when prescribed by the primary health care provider.
What should the pregnant client be taught to immediately eliminate in the first trimester to promote normal fetal organ development?
- A. Smoking
- B. Caffeine
- C. Alcohol
- D. Fatty foods
Correct Answer: C
Rationale: The first trimester, 'organogenesis,' is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this critical period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman. Eliminating consumption of alcohol during this time may promote normal fetal organ development. Although options 1, 2, and 3 may be concerns, they are not specifically associated with the first trimester of pregnancy.