Nokea
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
- A. SGOT and LDH
- B. SGOT and CK BB
- C. LDH and CK MB
- D. LDH and CK BB
Correct Answer: C
Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.
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A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Water will deplete electrolytes resulting in metabolic acidosis.
- B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
- D. Saline will increase peristalsis in the bowel.
Correct Answer: A
Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
Goal setting for a client with Meniere's disease should include which of the following?
- A. Frequent ambulation
- B. Prevention of a fall injury
- C. Consumption of three meals per day
- D. Prevention of infection
Correct Answer: B
Rationale: Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. Infection is not an anticipated problem.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.
A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
- A. Weight gain
- B. Weight loss
- C. Tachycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.
The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.