Nokea
The nurse is assessing the client’s bowel sounds. Which finding indicates normal bowel sounds?
- A. Stronger than normal
- B. Hypoactive
- C. Normal
- D. Hyperactive
Correct Answer: C
Rationale: Normal bowel sounds are described as 'normal,' occurring every 5–20 seconds with a gurgling quality. Stronger than normal or hyperactive sounds suggest increased motility (e.g., diarrhea), while hypoactive sounds indicate reduced motility (e.g., ileus).
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Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Tetralogy of Fallot
- B. Ventricular septal defect
- C. Patent ductus arteriosus
- D. Transposition of the great arteries
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
- A. Hyperglycemia
- B. Hypoglycemia
- C. Lack of development of the intestines
- D. Lack of development of the lungs
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which medication would the nurse expect to administer?
- A. Ibuprofen (Advil)
- B. Omeprazole (Prilosec)
- C. Aspirin
- D. Acetaminophen (Tylenol)
Correct Answer: B
Rationale: Omeprazole, a proton pump inhibitor, reduces acid production, aiding ulcer healing. Ibuprofen (A) and aspirin (C) worsen ulcers, and acetaminophen (D) addresses pain but not acid.
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.
The nurse is teaching a client with a history of fibromyalgia about self-care. The nurse should tell the client to:
- A. Engage in regular exercise
- B. Avoid all physical activity
- C. Increase caffeine intake
- D. Use heating pads excessively
Correct Answer: A
Rationale: Regular, low-impact exercise can reduce pain and stiffness in fibromyalgia, improving overall function and well-being.