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NEW QUESTION 45
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Abdominal pain
- D. Liquid stool
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
NEW QUESTION 46
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
- A. Cantaloupe
- B. Chicken
- C. Green beans
- D. Rice
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A (B) Rice contains about 4 g of protein per 200 g. (C) Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. (D) Green beans only contain 2 g of protein per cup.
NEW QUESTION 47
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Radial pulse for 2 minutes
- B. Respiratory rate for 1 minute
- C. Apical pulse for 1 minute
- D. Radial pulse for 1 minute
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Respiratory rate is not directly affected by digoxin therapy. (B) A radial pulse is not as accurate as an apical pulse. Dysrhythmias may not be detected. (C) A radial pulse is not as accurate as an apical pulse, regardless of assessment time. (D) Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
NEW QUESTION 48
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
- A. Lung immaturity
- B. Neural tube defect
- C. Intrauterine growth retardation (IUGR)
- D. Intrauterine infection
Answer: A
Explanation:
Explanation
(A) At about 30-32 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.
NEW QUESTION 49
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