Nokea
Which of the following conditions increases a client's risk of aspiration of stomach contents?
- A. A client is in restraints
- B. A client has a scaphoid abdomen
- C. A client is lying prone
- D. More than one answer is correct
Correct Answer: A
Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.
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A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?
- A. The registered nurse will be performing the procedure
- B. The procedure takes approximately 1 ? hours.
- C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
- D. The infant will continue to receive phototherapy during the procedure.
Correct Answer: B
Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.
A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication?
- A. This medication can cause severe drowsiness.
- B. The client must avoid foods that contain tyramine.
- C. The medication is associated with a high rate of abuse.
- D. The medication will begin to alleviate symptoms of depression almost immediately.
Correct Answer: B
Rationale: MAOIs are used to treat depression. Although MAOIs usually produce hypotension as a side effect, potentially lethal hypertension can occur if the client eats foods that contain tyramine. Such foods include aged cheeses, hot dogs, and beer, among others. The medication does not cause drowsiness, is not associated with a high rate of abuse, and does not act almost immediately.
The nurse instructs a client with mild preeclampsia about home care measures. Which statement by the client indicates to the nurse that the teaching has been effective concerning the assessment of complications for preeclampsia?
- A. I need to check my weight every day at different times during the day.
- B. I need to take my blood pressure each morning and alternate arms each time.
- C. I need to check my urine with a dipstick every day for protein and call the doctor if it is 2+ or more.
- D. As long as the home care nurse is visiting me daily, I do not have to keep my next primary health care provider's appointment.
Correct Answer: C
Rationale: Classic signs of preeclampsia include hypertension and proteinuria. The client diagnosed with preeclampsia needs to be instructed to report any increases in blood pressure; 2+ proteinuria; weight gain of more than 1 pound per week; the presence of edema in the face, hands, and sacral area; and decreased fetal activity to the primary health care provider immediately to prevent worsening of the preeclamptic condition. The weight needs to be checked at the same time each day, after voiding, before breakfast, and with the client wearing the same clothes in order to obtain reliable weight readings. Blood pressure measurements need to be taken in the same arm every day in a sitting position to obtain consistent and accurate readings. It is important to keep primary health care provider appointments even if the client is receiving visits from a home care nurse.
A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.
The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?
- A. Sodium restriction
- B. Increased fat intake
- C. Decreased carbohydrates
- D. Calorie restriction of 1500 daily
Correct Answer: A
Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000 . The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.