Nokea
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
- A. The infant exhibits dimpling of the cheeks.
- B. The infant makes smacking or clicking sounds.
- C. The mother's breast gets softer during a feeding.
- D. Milk drips from the mother's breast occasionally.
- E. The infant falls asleep after feeding less than 5 minutes.
- F. The infant can be heard swallowing frequently during a feeding.
Correct Answer: A,B,E
Rationale: Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition.
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The client states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
- A. Orthopnea
- B. Dyspnea at rest
- C. Dyspnea on exertion
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a 'three-point' position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
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.
The client is prescribed sotalol 80 mg orally twice daily. Which assessment finding indicates that the client is experiencing an adverse effect of the medication?
- A. Dry mouth
- B. Palpitations
- C. Diaphoresis
- D. Difficulty swallowing
Correct Answer: B
Rationale: Sotalol is a beta-adrenergic blocking agent that may be prescribed to treat chronic angina pectoris. Adverse effects include palpitations, bradycardia, an irregular heartbeat, difficulty breathing, signs of heart failure, and cold hands and feet. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness can also occur. Options 1, 3, and 4 are not adverse effects of this medication.
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 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.