Nokea
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator? Select all that apply.
- A. Audible crackles
- B. Client notably restless
- C. Visible mucus bubbling in the ET tube
- D. Apical pulse rate of 72 beats per minute
- E. Low peak inspiratory pressure on the ventilator
- F. High alarm pressures identified by the ventilator
Correct Answer: A,B,C,F
Rationale: Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high-pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.
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A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?
- A. Fetal descent
- B. Placenta previa
- C. Fetal lie and presentation
- D. Strength of uterine contractions
Correct Answer: C
Rationale: The first maneuver, the fundal grip, determines the contents (size, consistency, shape, and mobility) of the fundus (either the fetal head or breech) and thereby the fetal lie. Fetal descent is determined with the fourth maneuver. Placenta previa is diagnosed by ultrasound and not by palpation. Leopold maneuvers are not performed during a contraction.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to find documented in the client's medical record? Select all that apply.
- A. Edema
- B. Anemia
- C. Polyuria
- D. Bradycardia
- E. Hypotension
- F. Osteoporosis
Correct Answer: A,B
Rationale: The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.