Nokea
The nurse has admitted a client diagnosed with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?
- A. Seizures
- B. Hallucinations
- C. Placenta previa
- D. Altered respiratory status
Correct Answer: A
Rationale: Gestational hypertension can lead to preeclampsia and eclampsia; therefore, a major complication of gestational hypertension is seizures. Hallucinations, placenta previa, and altered respiratory status are not directly associated with gestational hypertension.
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The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item should be offered to the child?
- A. Green Jell-O
- B. Cold soda pop
- C. Butterscotch pudding
- D. Cool cherry-flavored Kool-Aid
Correct Answer: A
Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.
A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.
Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.
Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks' gestation?
- A. Fetal heart monitor
- B. An adult stethoscope
- C. Bell of a stethoscope
- D. Ultrasound fetoscope
Correct Answer: D
Rationale: Toward the end of the first trimester, the fetal heart tones can be heard with an ultrasound fetoscope. Options 2 and 3 are not designed to adequately assess the fetal heart rate. A fetal heart monitor is used during labor or in other situations when the fetal heart rate needs continuous monitoring.
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
- A. Hypovolemia
- B. Hypoglycemia
- C. Mood disturbances
- D. Deficient fluid volume
Correct Answer: C
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension.