Nokea
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
- A. Sherbet
- B. Steak sauce
- C. Apple juice
- D. Leafy green vegetables
Correct Answer: B
Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
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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.
The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis?
- A. An evening sweat potassium concentration greater than 60 mEq/L
- B. A sweat chloride concentration that is consistently greater 60 mEq/L
- C. An early morning sweat chloride concentration of less than 40 mEq/L
- D. A sweat potassium concentration that is consistently less than 40 mEq/L
Correct Answer: B
Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to the sweat test.
A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results?
- A. Proximal end of the distal stomach is anastomosed to the duodenum.
- B. Entire stomach is removed and the esophagus is anastomosed to the duodenum.
- C. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum.
- D. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum.
Correct Answer: C
Rationale: In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options 1, 2, and 4 are incorrect descriptions.
When a client with a chest injury is suspected of experiencing a pleural effusion, which typical manifestations of this respiratory problem should the nurse assess for? Select all that apply.
- A. Dry cough
- B. Moist cough
- C. Dyspnea at rest
- D. Productive cough
- E. Dyspnea on exertion
- F. Nonproductive cough
Correct Answer: A,E,F
Rationale: A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.
- A. Bradycardia
- B. Increased diaphoresis
- C. Decreased lacrimation
- D. Bowel and bladder incontinence
- E. Absent cough and swallow reflex
- F. Sudden marked rise in blood pressure
Correct Answer: B,D,E,F
Rationale: Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria.