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The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.
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The nurse has admitted a client diagnosed with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?
- A. Seizures
- B. Hallucinations
- C. Placenta previa
- D. Altered respiratory status
Correct Answer: A
Rationale: Gestational hypertension can lead to preeclampsia and eclampsia; therefore, a major complication of gestational hypertension is seizures. Hallucinations, placenta previa, and altered respiratory status are not directly associated with gestational hypertension.
Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose?
- A. Relieve postprocedure pain.
- B. Prevent thrombus formation.
- C. Prevent postprocedure hyperthermia.
- D. Prevent inflammation of the puncture site.
Correct Answer: B
Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client's long-term risk for injury?
- A. Change the client's positions slowly.
- B. Assess the client for decreased sensation to touch.
- C. Assess the client for decreased sensation to vibration.
- D. Teach the client about loss of motor function and decreased pain sensation.
Correct Answer: D
Rationale: Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter. Clinical findings related to anterior cord syndrome include loss of motor function, temperature sensation, and pain sensation below the level of injury. The syndrome does not affect sensations of fine touch, position, and vibration.
A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse should plan to keep which item available in the client's room to assist in this process?
- A. A urine strainer
- B. A calorie count sheet
- C. A vital signs graphic sheet
- D. An intake and output record
Correct Answer: A
Rationale: The urine is strained until the stone is passed, obtained, and analyzed. Straining the urine will catch small stones that should be sent to the laboratory for analysis. Once the type of stone is determined, an individualized plan of care for prevention and treatment is developed. Options 2, 3, and 4 are unrelated to the question.