Nokea
The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?
- A. Decreased abdominal girth
- B. Increased level of consciousness
- C. Weight maintenance
- D. Pulse rate decrease
Correct Answer: A
Rationale: Third-spacing is the translocation of fluid from the intravascular to intercellular space to tissue compartment. Anasarca is the general edema in the organ cavities such as the abdomen. Monitoring the abdominal girth provides data on the localization of the fluid in the interstitial space. A decrease in girth, in particular, notes improvement. Level of consciousness is not affected unless shock occurs. Weight remains the same as there is a shifting in fluid; pulse rate could fluctuate according to fluid movement.
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The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
- A. A blood pressure elevation upon activity
- B. A drop in systolic blood pressure $(15 \mathrm{~mm} \mathrm{Hg}$ ) upon rising
- C. A pulsating headache
- D. A drop in diastolic blood pressure $(25 \mathrm{mmHg}$ ) upon rising
Correct Answer: B
Rationale: Postural hypotension occurs when the client rises from a supine or semi- Fowler's position to a standing position and the systolic blood pressure drops by $15 \mathrm{~mm} \mathrm{Hg}$. The client has symptoms of dizziness or a near syncopal episode.
The nurse receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
- A. Call the health care provider with the report.
- B. Encourage the client to practice deep breathing.
- C. Finish the head-to-toe assessment.
- D. Obtain an ECG.
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?
- A. Hypervolemia
- B. Hypercalcemia
- C. Hypomagnesemia
- D. Hypermagnesemia
Correct Answer: C
Rationale: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
- A. A grilled chicken sandwich with mayonnaise
- B. A natural fruit salad with nuts
- C. A hot dog with ketchup
- D. A fresh grilled tuna entr?©e with fresh asparagus
Correct Answer: C
Rationale: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.
Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?
- A. Initiate an IV of an isotonic solution.
- B. Initiate an IV of albumin.
- C. Manage an infusion of plasma.
- D. Manage an infusion of total parenteral nutrition.
Correct Answer: B
Rationale: The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin. Administration of albumin pulls the trapped fluid back into the intravascular space. An isotonic solution will not pull water from the intercellular space. Blood products are used for third-spacing management; however, albumin is the product of choice. The management of total parenteral nutrition is not associated with third- spacing.