Nokea
The nurse is ambulating a client for the first time after having abdominal surgery. What clinical manifestations should indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply.
- A. Nausea
- B. Dizziness
- C. Bradycardia
- D. Lightheadedness
- E. Flushing of the face
- F. Reports of seeing spots
Correct Answer: A,B,D,F
Rationale: Orthostatic hypotension occurs when a normotensive person develops symptoms of low blood pressure when rising to an upright position. Whenever the nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension. Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result without intervention, which includes immediately assisting the client to a lying position.
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The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi's sarcoma. What characteristics would be consistent with that lesion? Select all that apply.
- A. Flat
- B. Raised
- C. Resembling a blister
- D. Light blue in color
- E. Brownish and scaly in appearance
- F. Color varies from pink to dark violet or black
Correct Answer: A,F
Rationale: Kaposi's sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy, and cryotherapy. None of the other options are associated with this type of lesion.
The nurse reviews the client's most recent blood gas results that include a pH of 7.43, PCO2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present?
- A. Compensated metabolic acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated respiratory acidosis
- D. Uncompensated metabolic alkalosis
Correct Answer: B
Rationale: The normal pH is 7.35 to 7.45, the normal PCO2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the PCO2 move in opposite directions; that is, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?
- A. Changing the toddler's diapers every 2 hours.
- B. Keeping the toddler's genital area open to the air.
- C. Implementing a 3-hour turning schedule for the toddler.
- D. Assessing the toddler's perineal area for redness regularly.
Correct Answer: A
Rationale: The spica cast is often needed to treat developmental hip dysplasia (DDH) or after hip/pelvis surgery. The cast encases the child's trunk and one or both legs while leaving access to the genital. Considering the age of the child, diapers will be in use and will need to be changed at least every 2 hours during the day and 3 to 4 hours during the night to help minimize the effect of urine and feces on the child's diaper area. Exposing the genital and perineal area to the air is an intervention that is implemented to assist in healing damaged skin tissue. Turning the child regularly is appropriate care but has no impact on the major issue of incontinence. Assessment of the skin is necessary but identifies skin breakdown once it has begun.
The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?
- A. Peeling of the skin
- B. Smooth soles without creases
- C. Lanugo covering the entire body
- D. Vernix that covers the body in a thick layer
Correct Answer: A
Rationale: The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo covering the entire body, and thick vernix covering the body.
A client experiencing difficulty breathing and increased pulmonary congestion was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment value indicates that the therapy has been effective?
- A. The lungs are now clear upon auscultation.
- B. The urine output has increased by 400 mL.
- C. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg.
- D. The serum potassium has decreased from 4.7 mEq to 4.1 mEq (4.7 mmol/L to 4.1 mmol/L).
Correct Answer: A
Rationale: Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.