Nokea
Which nursing implication is appropriate for a client undergoing a paracentesis?
- A. Have the client void before the procedure.
- B. Keep the client NPO.
- C. Observe the client for hypertension following the procedure.
- D. Place the client on the right side following the procedure.
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.
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A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?
- A. Mild fatigue
- B. Hypotension
- C. Slight headache
- D. Stable weight
Correct Answer: B
Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (A), headache (C), and stable weight (D) are less concerning.
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. A left hemothorax
- B. A right hemothorax
- C. Intubation of the right mainstem bronchus
- D. An inadequate mechanical ventilator
Correct Answer: C
Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
- A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
- B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
- C. The client will be more compliant with a medication that allows some feelings of hypomania.
- D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement every thirty minutes
Correct Answer: B
Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.