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What instruction should the nurse provide the parents of a 3-year-old boy with a BMI-for-age at
the 97th percentile?
Your child is tall for his age, so be sure he gets plenty to eat to stay healthy.
Your child is overweight for his age and size, so help him select more healthy foods.
Your child's weight is in the high range, but is probably normal for his body build.
Your child has very strong bones, so continue to maintain the same diet.
Your child is overweight for his age and size, so help him select more healthy foods.
Rationale:
Children with a BMI-for-age at or above the 95th percentile are considered overweight, and at
risk for obesity and all the associated health problems. The nurse should offer recommendations
for healthy eating and exercise.
When should the nurse conduct an Allen's test?
When pulmonary artery pressures are obtained.
Prior to attempting a cardiac output calculation.
To assess for presence of a deep vein thrombus in the leg.
Just before arterial blood gasses are drawn peripherally.
Just before arterial blood gasses are drawn peripherally.
Rationale:
The Allen's test should be performed prior to puncturing the radial artery to obtain a blood gas
specimen to determine patency of the ulnar artery in the selected extremity. To perform an
Allen's test the client's hand is formed into a fist while the nurse compresses the ulnar artery.
,Compression continues while the fist is opened. If blood perfusion through the radial artery is
adequate, the hand should flush and resume its normal pinkish coloration.
In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction.
Peripheral vasodilation.
Cardiac failure.
A vagal response.
Peripheral vasodilation.
,Rationale:
Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase
microvascular permeability at the site of the bacterial invasion.
A client with bleeding esophageal varices receives vasopressin IV. Which should the nurse
monitor for during the IV infusion of this medication?
Chest pain and dysrhythmia.
Vasodilation of the extremities.
Hypotension and tachycardia.
Decreasing GI cramping and nausea.
Chest pain and dysrhythmia.
Rationale:
In large doses, vasopressin may produce increased blood pressure, coronary insufficiency,
myocardial ischemia or infarction, and dysrhythmia.
The wife of a client diagnosed with Parkinson's disease tells the nurse that her husband is having
trouble swallowing and she is afraid he is going to choke. Which intervention should the nurse
implement?
Offer the wife assurance that difficulty with swallowing is usually temporary.
Encourage the couple to consider insertion of a nasogastric tube for tube feedings.
Teach the wife to thicken all liquids and serve primarily semi-solid foods.
Instruct wife to give carbidopa-levodopa 30-minutes before each meal.
Teach the wife to thicken all liquids and serve primarily semi-solid foods.
Rationale:
Dysphagia is usually a chronic problem for the client with Parkinson's disease. A semi-solid diet
with thick liquids is easier to swallow than solid foods.
Several clients on a busy antepartum unit are scheduled for procedures that require informed
consent. Which situation should the nurse explore further before witnessing the client's signature
on the consent form?
A 15-year-old primigravida who has been self-supporting for the past 6 months.
The obstetrician explained a procedure that a neurologist will perform.
The client was medicated for pain with a narcotic analgesic IM 6 hours ago.
The client is illiterate but verbalizes understanding and consent for the procedure.
The obstetrician explained a procedure that a neurologist will perform.
, Rationale:
The individual who is ultimately responsible for the procedure should provide the information
necessary for informed consent, so when an obstetrician explains the procedure scheduled to be