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The nurse is caring for a client who is receiving total parenteral nutrition and has a prescription for an intravenous intralipid infusion. What intervention should the nurse implement before hanging the intralipid infusion?
- A. Refrigerate the bottle of solution.
- B. Add 100 mL normal saline to the infusion bottle.
- C. Place an in-line filter on the administration tubing.
- D. Check the solution for separation or an oily residue.
Correct Answer: D
Rationale: Intralipids provide nonprotein calories and prevent or correct fatty acid deficiency. The nurse checks the solution for separation or an oily appearance because this can indicate a spoiled or contaminated solution. Refrigeration renders the intralipid solution too thick to administer. Because they can affect the stability of the solution, the nurse avoids injecting additives into the intralipid infusion. Furthermore, an in-line filter is not used because it can disrupt the flow of solution by becoming clogged.
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The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
- A. Checking for a rash on the digits
- B. Observing for softening of the nails or nail beds
- C. Palpating for a rapid or irregular peripheral pulse
- D. Palpating for diminished or absent peripheral pulses
Correct Answer: D
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition?
- A. Endometriosis is known as primary dysmenorrhea.
- B. Endometriosis is what causes me the pain that occurs when I ovulate.
- C. Endometriosis is the condition that has caused me to stop menstruating.
- D. Endometriosis means that I have uterine tissue growing outside my uterus.
Correct Answer: D
Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes.
The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
- A. Hypotension
- B. Photophobia
- C. Profuse sweating
- D. Decrease in urine output
Correct Answer: D
Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. None of the other options are associated with an adverse reaction to this medication.