Nokea
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.
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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).
To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse should regularly perform which assessment?
- A. Pulse rate
- B. Temperature
- C. Urine output
- D. Oxygen saturation
Correct Answer: C
Rationale: A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Polyuria of 4 to 24 L per day is characteristic of this complication. Options 1, 2, and 4 are not specifically related to a common complication after this surgery.
A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. Which expected prescription should the nurse immediately implement for this client? Select all that apply.
- A. Supplemental oxygen
- B. High Fowler's position
- C. Semi-Fowler's position
- D. Morphine sulfate intravenously
- E. Two tablets of acetaminophen with codeine
- F. Meperidine hydrochloride intravenously
Correct Answer: A,C,D
Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.