Nokea
The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.
You may also like to solve these questions
The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client's plan of care?
- A. Administer the prescribed amiodarone (Cordarone) immediately
- B. Institute a daily fluid restriction while the client is in the hospital
- C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
- D. Place the client in the Trendelenburg position to facilitate perfusion
Correct Answer: A
Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.
The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
- A. Consult the healthcare provider for recommendations on pain management
- B. Schedule the client for physical therapy to manage pain
- C. Recommend the client attend a support group for cancer patients
- D. Suggest alternative therapies like acupuncture or massage
Correct Answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Describes a schedule for antacid use in combination with other prescribed medications
- B. Selects a pattern of small meals interspersed with fluid intake
- C. Commits to engaging in a variety of stress reduction techniques
- D. Expresses a commitment to decrease nicotine intake
Correct Answer: B
Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.
When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?
- A. Psychological counseling to address emotional well-being
- B. Medication teaching concerning adrenergic blockers
- C. Preoperative and postoperative teaching for adrenalectomy
- D. Education on dietary modifications for hypertension
Correct Answer: C
Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.
An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?
- A. Observe for signs of deep vein thrombosis.
- B. Administer a PRN dose of a muscle relaxant.
- C. Check the client's most recent electrolyte values.
- D. Reduce the weight on the traction device.
Correct Answer: B
Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery. Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis. Choice C is not the most immediate action needed in this situation. Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.