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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 nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively?
- A. Cloudy sputum
- B. Shallow breathing
- C. Unilateral wheezing
- D. Productive coughing
Correct Answer: D
Rationale: Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions for expectoration, via vital client participation in recovery. Cloudy sputum, shallow breathing, and wheezing indicate that the incentive spirometry is not effective because they point to infection, counterproductive depth of breathing, and bronchoconstriction, respectively.
The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?
- A. Tissue hypoxia
- B. Chronic hypertension
- C. Delayed physical growth
- D. Destruction of bone marrow
Correct Answer: A
Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia. Options 2, 3, and 4 do not cause clubbing.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.
The nurse preparing to administer an intermittent tube feeding through a nasogastric (NG) tube assesses for residual volume. How do the resulting data assist in assuring the client's safety?
- A. Confirm proper NG tube placement.
- B. Determine the client's nutritional status.
- C. Evaluate the adequacy of gastric emptying.
- D. Assess the client's fluid and electrolyte status.
Correct Answer: C
Rationale: All stomach contents are aspirated and measured before administering a tube feeding to determine the gastric residual volume. If the stomach fails to empty and propel its contents forward, the tube feeding accumulates in the stomach and increases the client's risk of aspiration. If the aspirated gastric contents exceed the predetermined limit, the nurse withholds the tube feeding and collaborates with the primary health care provider on a plan of care. Assessing gastric residual volume does not confirm placement or assess fluid and electrolyte status. The nurse uses clinical indicators, including serum albumin levels, to determine the client's nutritional status.
The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
- A. Begin administering supplemental oxygen.
- B. Document the findings according to facility policies.
- C. Notify the child's primary health care provider immediately.
- D. Reassess the respiratory rate, rhythm, and depth in 15 minutes.
Correct Answer: B
Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.