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The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?
- A. Fetal descent
- B. Placenta previa
- C. Fetal lie and presentation
- D. Strength of uterine contractions
Correct Answer: C
Rationale: The first maneuver, the fundal grip, determines the contents (size, consistency, shape, and mobility) of the fundus (either the fetal head or breech) and thereby the fetal lie. Fetal descent is determined with the fourth maneuver. Placenta previa is diagnosed by ultrasound and not by palpation. Leopold maneuvers are not performed during a contraction.
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The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube?
- A. Pulling the tube back slightly
- B. Instructing the client to breathe slowly
- C. Continuing to advance the tube to the desired distance
- D. Checking the back of the pharynx using a tongue blade and flashlight
Correct Answer: C
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. The nurse should check the back of the pharynx using a tongue blade and flashlight to check for coiling and then pull the tube back slightly to prevent entrance into the larynx. Slow breathing helps the client relax to reduce the gag response.
The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
When a client's nasogastric (NG) tube stops draining, which intervention should the nurse implement to maintain client safety?
- A. Instill 10 to 20 mL of fluid to dislodge any clots.
- B. Verify the tube placement according to agency procedure.
- C. Clamp the tube for 2 hours to allow the drainage to accumulate.
- D. Retract the tube by 2 inches to be above and possible obstruction.
Correct Answer: B
Rationale: If a client's nasogastric tube stops draining, the nurse verifies placement first to ensure that the tube remains in the stomach. After checking placement and verifying a prescription for tube irrigation, the nurse irrigates the tube with 30 to 60 mL of the fluid per agency procedure. Clamping the tube increases the risk of aspiration and is contraindicated; besides, this intervention cannot unclog a tube. Retracting the tube may displace the tube and place the client at risk for aspiration.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
What should the nurse consider when determining whether a client diagnosed with a respiratory disease could tolerate and benefit from active progressive relaxation? Select all that apply.
- A. Social status
- B. Financial status
- C. Functional status
- D. Medical diagnosis
- E. Ability to expend energy
- F. Motivation of the individual
Correct Answer: C,D,E,F
Rationale: Active progressive relaxation training teaches the client how to effectively rest and reduce tension in the body. Some important considerations when choosing the type of relaxation technique are the client's physiological and psychological status. Because active progressive relaxation training requires a moderate expenditure of energy, the nurse needs to consider the client's functional status, medical diagnosis, and ability to expend energy. For example, a client with advanced respiratory disease may not have sufficient energy reserves to participate in active progressive relaxation techniques. The client needs to be motivated to participate in this form of alternative therapy to obtain beneficial results. The client's social or financial status has no relationship with her or his ability to tolerate and benefit from active progressive relaxation.