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What is the nurse's priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)?
- A. Maintaining the client on bed rest
- B. Ambulating the client in the hallway
- C. Encouraging the increased intake of oral fluids
- D. Encouraging the client to try to void frequently
Correct Answer: C
Rationale: After IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. The client is usually allowed activity as tolerated, without any specific activity guidelines. It is unnecessary to void frequently after the procedure.
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The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
- A. Colic
- B. Intussusception
- C. Congenital megacolon
- D. Hypertrophic pyloric stenosis
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
- A. A low-fiber diet with decreased fluids
- B. A low-sodium diet and fluid restriction
- C. A low-fat diet with a restriction of citrus fruits
- D. A low-carbohydrate diet and the elimination of red meats
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
- A. Immobility
- B. Risk of infection
- C. Altered independence
- D. Insufficient sensory stimulation
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.
Intravenous immune globulin (IVIG) therapy is prescribed for a child diagnosed with idiopathic thrombocytopenic purpura (ITP). What are the expected results of this medication?
- A. Urine positive for glucose and negative for protein
- B. Urine specific gravity of 1.020 and negative for red blood cells
- C. White blood cell count 18,000 mm^3 (18 × 10^9/L) and platelets 355,000 mm^3 (355 × 10^9/L)
- D. Blood urea nitrogen (BUN) 22 mg/dL (7.92 mmol/L) and creatinine levels of 2.1 mg/dL (185 mcmol/L)
Correct Answer: C
Rationale: IVIG is usually effective to rapidly increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids may be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies. Based on this information, the remaining options are unrelated to the administration of this medication.