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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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.
While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse should determine that the client is taking the medication to treat which disorder?
- A. Glaucoma
- B. Pyloric stenosis
- C. Renal insufficiency
- D. Urinary frequency and urgency
Correct Answer: D
Rationale: Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
The nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks' gestation. In what position should the nurse place the client to perform the procedure?
- A. In a standing position
- B. In the Trendelenburg position
- C. Supine with the head of the bed elevated to 45 degrees
- D. Supine with her head on a pillow and knees slightly flexed
Correct Answer: D
Rationale: When measuring fundal height, the client lies in a supine (back) position with her head on a pillow and knees slightly flexed. The standing position, Trendelenburg (head lowered), or supine with the head of the bed elevated to 45 degrees would prevent the nurse from getting an accurate measurement.
What is the smallest gauge catheter that the nurse can use to administer blood?
- A. 12 gauge
- B. 20 gauge
- C. 22 gauge
- D. 24 gauge
Correct Answer: B
Rationale: An intravenous catheter used to infuse blood should be at least 20 gauge or larger to help prevent additional hemolysis of red blood cells and to allow infusion of the blood without occluding the IV catheter.
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.
- A. Uterine irritability
- B. Uterine tenderness
- C. Painless vaginal bleeding
- D. Abdominal and low back pain
- E. Strong and frequent contractions
- F. Nonreassuring fetal heart rate patterns
Correct Answer: A,B,D,F
Rationale: Placental abruption, also referred to as abruptio placentae, is the separation of a normally implanted placenta before the fetus is born. It occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. Manifestations include uterine irritability with frequent low-intensity contractions, uterine tenderness that may be localized to the site of the abruption, aching and dull abdominal and low back pain, painful vaginal bleeding, and a high uterine resting tone identified by the use of an intrauterine pressure catheter. Additional signs include nonreassuring fetal heart rate patterns, signs of hypovolemic shock, and fetal death. Painless vaginal bleeding is a sign of placenta previa.