Nokea
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:
- A. In neurogenic shock, the skin is warm and dry
- B. In hypovolemic shock, there is a bradycardia
- C. In hypovolemic shock, capillary refill is less than 2 seconds
- D. In neurogenic shock, there is delayed capillary refill
Correct Answer: A
Rationale: Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia, and warm, dry skin. In hypovolemic shock, the client is hypotensive, tachycardiac, with cool skin and delayed capillary refill (>5 seconds).
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A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 5-1/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
- A. Provide food and fluids at the client's request
- B. Maintain IV, increasing the rate hourly until the client voids
- C. Report to the surgeon if the client is unable to void within 8 hours of surgery
- D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
Correct Answer: C
Rationale: Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.
A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.
Correct Answer: 21 pounds
Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- B. She places her infant on her right side after feeding her.
- C. She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.
- D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Correct Answer: C
Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.
The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?
- A. Sluggish bowel sounds
- B. Pain and tenderness at the umbilicus
- C. Passage of small amount of liquid stool
- D. Increasing abdominal girth
Correct Answer: D
Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.