Nokea
The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
- A. Monitor the client's blood sugar.
- B. Suction the mouth and pharynx every hour.
- C. Place the client in low Trendelenburg position.
- D. Encourage the client to cough.
Correct Answer: A
Rationale: Transphenoidal hypophysectomy can disrupt pituitary function, affecting glucose regulation. Monitoring blood sugar is critical to detect hypo- or hyperglycemia. Suctioning, positioning, or coughing is not routine.
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The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 900 mL/24 hr
- B. 1300 mL/24 hr
- C. 1600 mL/24 hr
- D. 2000 mL/24 hr
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
- A. Finger
- B. Earlobe
- C. Extremity with noninvasive BP cuff
- D. Nose
Correct Answer: C
Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.
Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it:
- A. Is also called intrinsic factor
- B. Must be given in the abdomen
- C. Requires use of the Z-track method
- D. Should be given SC
Correct Answer: C
Rationale: The Z-track method prevents staining and irritation when administering iron dextran parenterally in a large muscle.