Nokea
The nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which subjective finding supports the possibility of this condition?
- A. Experiences pain during intercourse
- B. Has pain at the onset of menstruation
- C. Experiences profuse vaginal bleeding
- D. Has sharp pelvic pain during ovulation
Correct Answer: D
Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by a growth follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
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The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?
- A. Pain management with an opioid
- B. Intravenous fluid therapy
- C. Oxygen administration
- D. Blood transfusion
Correct Answer: C
Rationale: The priority nursing intervention for a client in sickle cell crisis is to administer supplemental oxygen because the client is hypoxemic, and as a result, the red blood cells change to the sickle shape. In addition, oxygen is the priority because airway and breathing are more important than circulatory needs. The nurse also plans for fluid therapy to promote hydration and reverse the agglutination of sickled cells, opioid analgesics for relief from severe pain, and blood transfusions (rather than iron administration) to increase the blood's oxygen-carrying capacity.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect?
- A. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute
- B. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute
- C. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute
- D. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute
Correct Answer: B
Rationale: The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication.
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
A client prescribed warfarin sodium has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? Select all that apply.
- A. Tea
- B. Turnips
- C. Oranges
- D. Cabbage
- E. Broccoli
- F. Strawberries
Correct Answer: A,B,D,E
Rationale: Warfarin sodium is an anticoagulant that interferes with the hepatic synthesis of vitamin K-dependent clotting factors. The client is instructed to limit the intake of foods high in vitamin K while taking this medication. These foods include coffee or tea (caffeine), turnips, cabbage, broccoli, greens, fish, and liver.