Nokea
Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome?
- A. Weight
- B. Albumin levels
- C. Activity tolerance
- D. Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention.
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A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.
The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.
Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose?
- A. Relieve postprocedure pain.
- B. Prevent thrombus formation.
- C. Prevent postprocedure hyperthermia.
- D. Prevent inflammation of the puncture site.
Correct Answer: B
Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation.
A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway?
- A. Insert oropharyngeal airway.
- B. Tilt the head and lift the chin.
- C. Place in the recovery position.
- D. Stabilize the skull and push up the jaw.
Correct Answer: D
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.