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The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.
- A. Yellowish sclera
- B. Reports of severe fatigue
- C. Pink mucous membranes
- D. Increased vaginal secretions
- E. Reports of frequent headaches
- F. Reports of increased frequency of voiding
Correct Answer: B,E
Rationale: Iron deficiency anemia is described as a hemoglobin blood concentration of less than 10.5 to 11.0 g/dL (105 to 110 mmol/L). Complaints of headaches and severe fatigue are abnormal findings and may reflect complications of this type of anemia caused by the decreased oxygen supply to vital organs. Options 3, 4, and 6 are normal findings in the first trimester of pregnancy. Yellow sclera (whites of the eyes) is associated with jaundice.
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The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply.
- A. Anosmia
- B. Chronic cough
- C. Blurry vision
- D. Nasal stuffiness
- E. Purulent nasal discharge
- F. Headache that worsens in the evening
Correct Answer: A,B,D,E
Rationale: Chronic sinusitis is characterized by anosmia (loss of smell), a chronic cough resulting from nasal discharge, nasal stuffiness, persistent purulent nasal discharge, and headache that is worse upon arising after sleep. Blurred vision is not associated directly to this condition.
The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
While preparing to administer an intravenous (IV) medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention should the nurse implement to assure the client's safety?
- A. Ask the provider to prescribe a compatible IV solution.
- B. Start a new IV catheter for the incompatible medication.
- C. Collaborate with the provider for a new administration route.
- D. Flush tubing before and after administering the medication with normal saline.
Correct Answer: D
Rationale: When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route is unnecessary because a simpler, less risky, viable option exists.
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
- A. Atrial fibrillation
- B. Sinus dysrhythmia
- C. Ventricular fibrillation
- D. Third-degree heart block
Correct Answer: A
Rationale: Atrial fibrillation is characterized by rapid, chaotic atrial depolarization. Ventricular rates may be less than 100 beats per minute (controlled) or greater than 100 beats per minute (uncontrolled). The ECG reveals chaotic or no identifiable P waves and an irregular ventricular rhythm. A sinus dysrhythmia has a normal P wave and PR interval and QRS complex. In ventricular fibrillation, there are no identifiable P waves, QRS complexes, or T waves.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.