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The nurse plans care for a client requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
- A. Hyponatremia
- B. Bounding pulse rate
- C. Chronic kidney disease
- D. Isolated syncope episodes
- E. Rapid, weak, and thready pulse
- F. Abnormal serum and urine osmolality levels
Correct Answer: A,E,F
Rationale: Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.
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A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Meconium aspiration syndrome
- D. Transient tachypnea of the newborn
Correct Answer: C
Rationale: Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome (MAS). MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. The symptoms noted in the question are unrelated to hypoglycemia. Respiratory distress syndrome is a complication of preterm infants. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- C. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
- D. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Correct Answer: B
Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse should explain it is from which source?
- A. A cadaver
- B. Another animal species
- C. The burned client themselves
- D. A man-made synthetic source
Correct Answer: B
Rationale: Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pig skin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client. Synthetic dressings are also available for covering burn wounds.
A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply.
- A. Restrict the client's movements.
- B. Turn the supine client to the side.
- C. Open the unconscious client's airway.
- D. Gently guide the standing client to the floor.
- E. Place a padded tongue blade into the client's mouth.
- F. Loosen any restrictive clothing that the client is wearing.
Correct Answer: B,C,D,F
Rationale: Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.
The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?
- A. Discourage the client from walking.
- B. Increase the rate of the oxytocin infusion.
- C. Monitor the fetal heart rate every 30 minutes.
- D. Encourage upright or side-lying maternal positions.
Correct Answer: D
Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention.