Nokea
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.
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A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
The nurse is assessing elderly clients at a community center.
- A. Dry mouth
- B. Loss of one inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (A), height loss (B), and stiffened joints (C) are common in aging but less urgent.
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
- A. Hyperglycemia
- B. Hypoglycemia
- C. Lack of development of the intestines
- D. Lack of development of the lungs
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
- A. Extreme weight loss
- B. Presence of lanugo over body
- C. Erosion of tooth enamel
- D. Muscle wasting
Correct Answer: C
Rationale: Bulimia nervosa involves recurrent binge eating followed by purging, often through vomiting, which exposes teeth to stomach acid, leading to enamel erosion. Extreme weight loss and lanugo are more characteristic of anorexia nervosa, and muscle wasting is not a primary feature of bulimia.
A 12-year-old girl has been diagnosed with insulin-dependent diabetes mellitus. Which of these principles would best guide her nutritional management?
- A. Concentrated sweets are taken during increased activity.
- B. Food restriction is imposed to reduce weight.
- C. Caloric distribution should be calculated to fit activity patterns.
- D. Fat requirements are increased owing to the possibility of ketoacidosis.
Correct Answer: C
Rationale: Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern. Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained. Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.