Saturday, 23 March 2019

Question Of The Day, Respiratory Disorders
Q. A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A. Nausea or vomiting
B. Abdominal pain or diarrhea
C. Hallucinations or tinnitus
D. Light-headedness or paresthesia



Correct Answer: D

Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

Friday, 22 March 2019

Q. A nurse is monitoring a client for adverse reactions to atropine (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

A. Tachycardia
B. Increased salivation
C. Hypotension
D. Apnea


Correct Answer: A

Explanation: Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.

Wednesday, 20 March 2019

Q. A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

A. Recent weight gain of 20 lb (9.1 kg)
B. Failure to monitor blood glucose levels
C. Skipping insulin doses during illness
D. Crying whenever diabetes is mentioned



Correct Answer: D

Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

Tuesday, 19 March 2019

Q. A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

A. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."
B. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal."
C. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."
D. "I will receive parenteral vitamin B12 therapy for the rest of my life."

Correct Answer: D

Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.




Saturday, 16 March 2019

Q. In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:

A. The client will remain in the ICU for 5 days.
B. The client will sleep most of the time while in the ICU.
C. Noise and activity within the ICU are minimal.
D. The client will receive medication to relieve pain.

Correct Answer: D

Explanation: Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.


Friday, 15 March 2019

Q. A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should:

A. Notify the primary care provider.
B. Administer the ordered fluids.
C. Verify that the infant has urinated.
D. Have the potassium level redrawn.

Correct Answer: C

Explanation: Normal serum potassium levels are 3.5-4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4Meq/l is not unexpected and should be corrected with the ordered fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.


Thursday, 14 March 2019

Q. Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?

A. Document this as a normal finding in the client's record.
B. Contact the physician for an order for methylergonovine (Methergine).
C. Encourage the client to ambulate to the bathroom and void.
D. Gently massage the fundus to expel the clots.

Correct Answer: C

Explanation: At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Methylergonovine (Methergine) is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.

Wednesday, 13 March 2019

Question Of The Day, Intrapartum Period
Q. The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?

A. Tell the client to push between contractions.
B. Provide gentle support to the fetal head.
C. Apply gentle upward traction on the neonate's anterior shoulder.
D. Massage the perineum to stretch the perineal tissues.

Correct Answer: B

Explanation: During a precipitous delivery, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe delivery of the infant over protecting the perineum by massage.


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