Nokea
The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
- A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
- B. To prevent infection, the dressing should be kept dry to avoid excess moisture
- C. The skin incision should be kept moist to promote healing and prevent dryness
- D. The incision should be protected from fecal contamination by an intact dressing
Correct Answer: D
Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
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Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
- A. Intravenous administration of thyroid hormones
- B. Oral administration of hypnotic agents
- C. Intravenous bolus of hydrocortisone
- D. Subcutaneous administration of vitamin K
Correct Answer: A
Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor for signs of activity intolerance
- B. Require visitors to wear respiratory masks
- C. Assess urine and stool for occult blood
- D. Obtain client's temperature q4 hours
Correct Answer: C
Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.
The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?
- A. Assess extremity strength and resistance
- B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
- C. Measure and record the cardiac QRS complex
- D. Check current finger stick glucose
Correct Answer: D
Rationale: The client's symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.
Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Validate the client's understanding of the surgical procedure to be conducted
- B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
- C. Ensure the client, not a family member, signs the surgical consent form
- D. Confirm that the surgical consent form is signed and included in the client's record
Correct Answer: A
Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)
- A. Increased heart rate
- B. Visual disturbances
- C. Presence of uremic frost
- D. Decreased mentation
Correct Answer: A
Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.