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Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS.
Incorrect choices:
A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax.
C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders.
D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.
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The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. The written outcomes are designed to meet nursing goals
- B. To encourage the client and family to be involved
- C. To discourage additions by other healthcare providers
- D. Why the nurse believes the outcome is important
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.
A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
- A. Prevent infection postoperatively
- B. Eliminate the need for preoperative enemas
- C. Decreased and retard the growth of normal bacteria in the intestines
- D. Treat cancer of the colon
Correct Answer: C
Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
- A. Position the client flat for at least 3 hrs or as directed by the physician
- B. Encourage a liberal fluid intake
- C. Keep the room well lit and play some soothing music in the ground
- D. Help the client ambulate and perform a few light leg exercises#
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician.
Rationale:
1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal.
2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache.
3. Following physician's direction is crucial to individualize care based on the specific situation.
Summary of other choices:
B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache.
C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms.
D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.