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The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
- A. Elevate the head of the bed.
- B. Provide oxygen during stressful periods.
- C. Limit the time that the infant is allowed to bottle-feed.
- D. Wake the infant for feedings to ensure adequate nutrition.
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.
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The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
- A. A kink in the tube
- B. The client fighting the ventilator
- C. Increased secretions in the airway
- D. A cuff leak in the endotracheal tube
- E. The client biting on the endotracheal tube
- F. The ventilator tubing disconnecting from the endotracheal tube
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.
A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?
- A. Bland
- B. Full liquids
- C. Clear liquids
- D. Semisolid foods
Correct Answer: D
Rationale: Oral intake after laryngectomy is started with semisolid foods. When the client can manage this type of food, liquids may be introduced. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. Thin liquids are not given until the risk of aspiration is negligible.
A client has received a dose of an as-needed medication loperamide. The nurse evaluates the client after administration to determine if the client has relief of which sign/symptom?
- A. Diarrhea
- B. Tarry stools
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Loperamide is an antidiarrheal agent, and it is commonly administered after loose stools. It is used for the management of acute diarrhea and also for chronic diarrhea, such as with inflammatory bowel disease. It can also be used to reduce the volume of drainage from an ileostomy. It is not intended to treat any of the other options.
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
- A. I am in control of myself now.
- B. I need to use the restroom right away.
- C. I'd like to go back to my room and be alone for a while.
- D. I can't breathe in here. It feels like the walls are closing in on me.
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.