Nokea
The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?
- A. Call the physician.
- B. Irrigate the NG tube.
- C. Check the function of the suction equipment.
- D. Reposition the NG tube.
Correct Answer: C
Rationale: Checking the suction equipment ensures the NG tube is functioning properly, addressing the most likely cause of distention before escalating to other interventions.
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A client with a history of heart failure is prescribed torsemide (Demadex). The nurse should monitor the client for which of the following adverse effects?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Torsemide, a loop diuretic, can cause hypokalemia.
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
- A. It usually resolves when treated with vasodilator medications.
- B. It is similar to stroke, but all symptoms will go away eventually.
- C. It is not caused by stroke, and many clients recover in 3 to 5 weeks.
- D. It is not caused by a tumor, and many clients recover in 3 to 5 weeks.
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
- A. Spina bifida cystica.
- B. Spina bifida occulta.
- C. Meningocele.
- D. Myelomeningocele.
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Urine retention.
- D. Costovertebral tenderness.
Correct Answer: D
Rationale: Costovertebral tenderness is a hallmark of pyelonephritis, indicating kidney involvement, unlike the other symptoms, which are more typical of cystitis.