Nokea
The nurse caring for an infant demonstrating diarrhea should monitor the infant for which early sign of dehydration?
- A. Cool extremities
- B. Gray, mottled skin
- C. Capillary refill of 3 seconds
- D. Apical pulse rate of 200 beats per minute
Correct Answer: D
Rationale: Dehydration causes interstitial fluid to shift to the vascular compartment in an attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory failure occurs. The blood pressure will decrease and the pulse rate will increase. This will be followed by peripheral symptoms.
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The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
- A. Older clients tend to be incontinent.
- B. Older clients are at risk for dehydration.
- C. Depression is a normal part of the aging process.
- D. Age-related skin changes require special monitoring.
- E. Older clients are at risk for complications of immobility.
- F. Confusion and cognitive changes are common findings in the older population.
Correct Answer: B,D,E
Rationale: Older clients are at risk for dehydration and complications related to immobility. Another normal physiological change that occurs during the aging process is loss of skin integrity. Incontinence, depression, confusion, and cognitive changes are not normal parts of the aging process.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?
- A. Waves of loud gurgles auscultated in all four quadrants
- B. Soft gurgling or clicking sounds auscultated in all four quadrants
- C. Low-pitched swishing sounds auscultated in one or two quadrants
- D. Very high-pitched loud rushes auscultated, especially in one or two quadrants
Correct Answer: B
Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction.
The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury?
- A. Hypothermia blanket
- B. Emergency tracheostomy kit
- C. Magnesium sulfate in a ready-to-inject vial
- D. Ampule of saturated solution of potassium iodide
Correct Answer: B
Rationale: Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state.
A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
- A. Palpate the pedal pulses.
- B. Measure the abdominal girth.
- C. Assess the client about the level of pain in the area.
- D. Auscultate over the iliac area with a Doppler device.
Correct Answer: B
Rationale: Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected.