Nokea
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Clients with an axillopopliteal bypass graft should avoid prolonged sitting in a straight chair, as it can compress the graft and impair blood flow. Reclining, supine, or Sim’s positions are less likely to compromise the graft.
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A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.'
- B. A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'
- C. These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'
- D. This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'
Correct Answer: C
Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?
- A. Creatinine
- B. Sodium
- C. Calcium
- D. Potassium
Correct Answer: A
Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:
- A. He will manipulate the other clients for his own benefit
- B. He will cause the other clients to become psychotic
- C. He will become delusional and hallucinate as a result of the excess attention given to him by peers
- D. He may exhibit self-mutilative behavior
Correct Answer: A
Rationale: This answer is correct. Persons with antisocial personality disorder typically are very manipulative. This answer is incorrect. The client's behavior cannot cause another person to become psychotic. This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.