Nokea
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
- A. Impaired gas exchange related to hyperventilation
- B. Alteration in placental perfusion related to maternal position
- C. Impaired physical mobility related to fetal-monitoring equipment
- D. Potential fluid volume deficit related to decreased fluid intake
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.
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A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
- A. Pneumonia
- B. Pulmonary contusions
- C. Pulmonary edema
- D. Tension pneumothorax
Correct Answer: B
Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
- A. Shake the inhaler and listen for the contents.
- B. Drop the inhaler in water to see if it floats.
- C. Check for a hissing sound as the inhaler is used.
- D. Press the inhaler and watch for the mist.
Correct Answer: B
Rationale: Dropping the inhaler in water to see if it floats is a practical way to estimate remaining medication; a half-empty inhaler will float, while a full one sinks.
The client has an order for sliding scale insulin at 1900 hours and Lantus (glargine) insulin at the same hour. The nurse should:
- A. Administer the two medications together.
- B. Administer the two medications in two injections.
- C. Draw up the Lantus insulin and then the regular insulin and administer them together.
- D. Contact the doctor because these medications should not be given to the same client.
Correct Answer: B
Rationale: Lantus (glargine) is a long-acting insulin and should not be mixed with short-acting sliding scale insulin (e.g. regular insulin) due to differing pharmacokinetics. Administering them in separate injections ensures proper action profiles.
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
- A. Placing the client in a prone position
- B. Maintaining strict bed rest for 24 hours
- C. Offering a clear liquid diet
- D. Instructing the client to keep his head bowed when sitting upright
- E. Applying an eye patch to protect the affected eye from light
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (A) to keep oil against the retina, head bowed when upright (D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (B) is not strict, and diet (C) progresses as tolerated.