Nokea
To facilitate maximum air exchange, the nurse should position the client in:
- A. High Fowler
- B. Orthopneic
- C. Prone
- D. Flat-supine
Correct Answer: B
Rationale: The orthopneic position is a sitting position that allows maximum lung expansion.
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The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. Tetracycline treatment
- C. IV amphotericin B
- D. High-protein diet with limited fluids
Correct Answer: B
Rationale: The client is not placed on complete bed rest for 6 weeks. Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. IV amphotericin B is the treatment for histoplasmosis. The client is not restricted to a high-protein diet with limited fluids.
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. Prolonged bed rest
- B. The client's maintaining a semi-Fowler position
- C. Cerebral hypoxia
- D. IV fluids of 2.5-3 liters in 24 hours
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
- A. Start the child on solid food.
- B. Nurse the child more frequently during this growth spurt.
- C. Provide supplements for the child between breastfeeding so you will have enough milk.
- D. Wait 4 hours between feedings so that your breasts will fill up.
Correct Answer: B
Rationale: Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
- A. Complaints of dyspnea
- B. Edema of face and hands
- C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
- D. Hematocrit 39%
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
- A. He should monitor his sputum, stools, and urine for signs of bleeding.
- B. His daily diet should include a large amount of fluid.
- C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
- D. He should not worry about having children because this disease is passed on only by female carriers.
Correct Answer: B
Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.