Nokea
The nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks' gestation. In what position should the nurse place the client to perform the procedure?
- A. In a standing position
- B. In the Trendelenburg position
- C. Supine with the head of the bed elevated to 45 degrees
- D. Supine with her head on a pillow and knees slightly flexed
Correct Answer: D
Rationale: When measuring fundal height, the client lies in a supine (back) position with her head on a pillow and knees slightly flexed. The standing position, Trendelenburg (head lowered), or supine with the head of the bed elevated to 45 degrees would prevent the nurse from getting an accurate measurement.
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To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse should regularly perform which assessment?
- A. Pulse rate
- B. Temperature
- C. Urine output
- D. Oxygen saturation
Correct Answer: C
Rationale: A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Polyuria of 4 to 24 L per day is characteristic of this complication. Options 1, 2, and 4 are not specifically related to a common complication after this surgery.
A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication?
- A. Infuse over 1 hour and allow the client to ambulate.
- B. Infuse over 1 hour with the client in a supine position.
- C. Administer over 30 minutes with the client in a reclining position.
- D. Administer by IV push over 15 minutes with the client in a supine position.
Correct Answer: B
Rationale: IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position.
The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated?
- A. Strip the tubing and assess for a blood return.
- B. Check the regional tissue for redness and warmth.
- C. Increase the infusion rate and observe for swelling.
- D. Gently palpate regional tissue for edema and coolness.
Correct Answer: D
Rationale: When assessing an IV for clinical indicators of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the surrounding tissues, which can increase the risk of tissue damage. Redness and warmth are more likely to indicate infection or phlebitis.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.
A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury?
- A. Obtaining a chest x-ray
- B. Assessing blood pressure and pulse
- C. Obtaining a complete blood cell count and liver function studies
- D. Scheduling a drug level to be drawn 1 hour after the dose is administered
Correct Answer: B
Rationale: Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.