Nokea
The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness?
- A. Monitor the client's weight.
- B. Monitor the client's intake and output.
- C. Calculate the client's daily caloric intake.
- D. Frequently check the client's serum protein levels.
Correct Answer: A
Rationale: The most accurate measurement of weight loss is weighing of the client. This should be done at the same time of the day, in the same clothes, and using the same scale. Options 2, 3, and 4 measure nutrition and hydration status but are not associated with effectiveness of the weight loss program.
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A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats per minute (BPM), and respirations (R) 20 breaths per minute. The nurse administers nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data?
- A. BP 150/90 mm Hg, P 70 BPM, R 24 breaths per minute
- B. BP 100/60 mm Hg, P 96 BPM, R 20 breaths per minute
- C. BP 100/60 mm Hg, P 70 BPM, R 24 breaths per minute
- D. BP 160/100 mm Hg, P 120 BPM, R 16 breaths per minute
Correct Answer: B
Rationale: Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the blood pressure to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta blockers, such as propranolol, are often used in conjunction with nitroglycerin to prevent this rise in heart rate. If chest pain is reduced and cardiac workload is reduced, the client will be more comfortable; therefore, a rise in respirations should not be seen.
A client diagnosed with left pleural effusion has just been admitted for treatment. The nurse should plan to have which procedure tray available for use at the bedside?
- A. Intubation
- B. Paracentesis
- C. Thoracentesis
- D. Central venous line insertion
Correct Answer: C
Rationale: The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid from the pleural space, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case that the client's symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion. Options 1 and 4 are not specifically indicated for this procedure.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
A client is resuming a diet after a Billroth II procedure. To minimize complications associated with eating, which actions should the nurse teach the client? Select all that apply.
- A. Laying down after eating
- B. Eating a diet high in protein
- C. Drinking liquids with meals
- D. Eating six small meals per day
- E. Eating concentrated sweets only between meals
Correct Answer: A,B,D
Rationale: The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should lie down after eating and avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.
During a routine prenatal visit, a client in her third trimester of pregnancy reports having frequent calf pain when she walks. The nurse suspects superficial thrombophlebitis and checks for which sign associated with this condition?
- A. Severe chills
- B. Kernig's sign
- C. Brudzinski's sign
- D. Palpable hard thrombus
Correct Answer: D
Rationale: Pain in the calf during walking could indicate venous thrombosis or peripheral arterial disease. The manifestations of superficial thrombophlebitis include a palpable thrombus that feels bumpy and hard, tenderness and pain in the affected lower extremity, and a warm and pinkish red color over the thrombus area. Severe chills can occur in a variety of inflammatory or infectious conditions and are also a manifestation of pelvic thrombophlebitis. Brudzinski's sign and Kernig's sign test for meningeal irritability.