Nokea
Which conditions place the client receiving enteral nutrition at increased risk for aspiration? Select all that apply.
- A. Sedation
- B. Coughing
- C. An artificial airway
- D. Head-elevated position
- E. Nasotracheal suctioning
- F. Decreased level of consciousness
Correct Answer: A,B,C,E,F
Rationale: A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Some common conditions that increase the risk of aspiration include sedation, coughing, an artificial airway, nasotracheal suctioning, decreased level of consciousness, and lying flat. A head-elevated position does not increase the risk of aspiration.
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A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
- A. Edema
- B. Proteinuria
- C. Hypertension
- D. Abdominal pain
- E. Increased weight
- F. Hypoalbuminemia
Correct Answer: A,B,D,E,F
Rationale: Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.
A client is diagnosed with cholecystitis. The nurse reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.
- A. Dyspepsia
- B. Dark stools
- C. Light-colored and clear urine
- D. Feelings of abdominal fullness
- E. Rebound tenderness in the abdomen
- F. Upper abdominal pain that radiates to the right shoulder
Correct Answer: A,D,E,F
Rationale: Cholecystitis is an inflammation of the gallbladder. Manifestations include dyspepsia; feelings of abdominal fullness; rebound tenderness (Blumberg's sign); upper abdominal pain or discomfort that can radiate to the right shoulder; pain triggered by a high-fat meal; clay-colored stools, dark urine, and possible steatorrhea; anorexia, nausea, and vomiting; eructation; flatulence; fever; and jaundice.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
The home care nurse is making a follow-up visit to a client after receiving a renal transplant. Which assessment data support the possible existence of acute graft rejection? Select all that apply.
- A. Pale skin color
- B. Urine output of 45 mL/hour
- C. Blood pressure of 164/98 mm Hg
- D. Temperature of 102.4°F (39.1°C)
- E. Client reporting 'feeling so very tired'
- F. Client reporting that graft site is tender when touched
Correct Answer: C,D,E,F
Rationale: Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years after transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is immediately begun with corticosteroids and possibly also with monoclonal antibodies and antilymphocytic agents. None of the other options present symptomology associated with acute graft rejection.
A client is resuming a diet after a Billroth II procedure. To minimize complications associated with eating, which actions should the nurse teach the client? Select all that apply.
- A. Laying down after eating
- B. Eating a diet high in protein
- C. Drinking liquids with meals
- D. Eating six small meals per day
- E. Eating concentrated sweets only between meals
Correct Answer: A,B,D
Rationale: The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should lie down after eating and avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.