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Which is an important nursing consideration when suctioning a young child who has had heart surgery?
- A. Perform suctioning at least every hour.
- B. Suction for no longer than 30 seconds at a time.
- C. Administer supplemental oxygen before and after suctioning.
- D. Expect symptoms of respiratory distress when suctioning.
Correct Answer: B
Rationale: Suctioning for no longer than 30 seconds at a time is an important nursing consideration when suctioning a young child who has had heart surgery. Prolonged suctioning can cause hypoxemia and decrease the child's oxygen saturation, which can be detrimental, especially in postoperative patients who may have compromised cardiopulmonary reserves. It is crucial to minimize the duration of suctioning to prevent potential complications. Additionally, hyperoxygenation before and after suctioning may help maintain adequate oxygen levels and minimize the risk of hypoxemia in these vulnerable patients.
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Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.
The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
- A. "I should avoid tub baths but may shower."
- B. "I have to stay on strict bed rest for 3 days."
- C. "I should remove the pressure dressing the day after the procedure."
- D. "I may attend school but should avoid exercise for several days."
Correct Answer: B
Rationale: The statement "I have to stay on strict bed rest for 3 days" would indicate a need for further teaching. After a cardiac catheterization, strict bed rest is usually not required for an extended period of time. The patient is typically advised to limit physical activities for a certain period but can engage in light activities as tolerated. Prolonged bed rest can increase the risk of complications such as blood clots and muscle weakness. It would be important to clarify this misconception and provide accurate information regarding post-procedure care.
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: Acetaminophen toxicity can lead to hepatic injury, resulting in elevated liver enzymes, including bilirubin levels. Direct bilirubin is a specific marker for liver function and is typically elevated in cases of acetaminophen overdose or toxicity. Therefore, a direct bilirubin level of 2 mg/dl would indicate toxicity associated with acetaminophen use. Monitoring liver function tests, including bilirubin levels, is crucial when using acetaminophen long-term to prevent toxicity and liver damage.
A nurse is establishing several health programs, such as bicycle safety, to improve the health status of a target population. This describes which step in the community nursing process?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Implementation
Correct Answer: D
Rationale: The nurse establishing health programs, such as bicycle safety, to improve the health status of a target population is engaging in the implementation phase of the community nursing process. Implementation involves putting the planned interventions into action. In this scenario, the nurse is actively carrying out the health programs to promote bicycle safety, which is a crucial step in the community nursing process. The planning phase precedes implementation, where the nurse develops the interventions and strategies to address community health needs. Following implementation, the next step in the community nursing process would be evaluation, where the effectiveness of the health programs would be assessed to determine their impact on the target population.
An adolescent girl asks the school nurse for advice because she has dysmenorrhea. She says that a friend recommended she try an over-the-counter nonsteroidal anti-inflammatory drug (NSAID). The nurse's response should be based on which statement?
- A. Aspirin is the drug of choice for the treatment of dysmenorrhea.
- B. Over-the-counter NSAIDs are rarely strong enough to provide adequate pain relief.
- C. NSAIDs are effective because of their analgesic effect.
- D. NSAIDs are effective because they inhibit prostaglandins, leading to reduction in uterine activity.
Correct Answer: D
Rationale: NSAIDs are effective for treating dysmenorrhea because they work by inhibiting prostaglandins, which are responsible for causing increased uterine activity and thus pain during menstruation. By reducing prostaglandin levels, NSAIDs help to decrease uterine contractions and consequently alleviate menstrual cramps. This mechanism of action makes NSAIDs an appropriate and effective choice for managing dysmenorrhea.