Nclex Style Questions And Anwsers On Critical Thinking
Antihypertensive medications, such as enalapril, are administered to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis.
The sigmoid and descending colon are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus.
Respiratory distress can occur following thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. SSKI is typically administered preoperatively to block thyroid hormone synthesis and release, as well as place the client in a euthyroid state. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem post-thyroidectomy.
Sodium nitroprusside becomes unstable when exposed to light and must be protected.
The use of an incisional splint such as a "cough pillow" can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated.
All stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual, which is determined in order to evaluate whether undigested formula from a previous feeding remains. It is important to assess gastric residual because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. Assessing residual does not confirm placement, determine patency, or assess fluid and electrolyte status.
Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen.
Breathing and relaxation techniques aid the client in coping with the discomfort of labor and in conserving energy. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous.
Autonomic dysreflexia (hyperreflexia) is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. A client with autonomic dysreflexia would be hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
IV nitroglycerin is prepared only in glass bottles, using the administration sets provided. Standard plastic (polyvinyl chloride) tubing will adsorb the nitroglycerin, thus reducing the potency and reliability of the medication. It should also be protected from extremes of light and temperature. It should be remixed every 4 hours.
The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case the client's symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion.
