Nokea
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To prevent respiratory obstruction
- C. To help the client drink fluids
- D. To prevent excessive bleeding
Correct Answer: B
Rationale: An ice collar may be ordered for a client undergoing drainage of a peritonsillar abscess to prevent respiratory obstruction. Peritonsillar abscess is a collection of pus behind the tonsils, and the inflammation and swelling from the abscess can lead to difficulty in breathing or swallowing. Applying an ice collar can help reduce the swelling and prevent the abscess from compressing the airway, thus reducing the risk of respiratory obstruction. It can provide comfort to the client and support the drainage process by minimizing the swelling and promoting better drainage of the abscess.
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Baby Ellie is diagnosed with gastroesophageal reflux (GER); which of the following nursing diagnoses would be inappropriate?
- A. Risk for aspiration
- B. Impaired oral mucous membrane
- C. Deficient fluid volume
- D. Imbalanced nutrition: Less than body requirements
Correct Answer: B
Rationale: Gastroesophageal reflux (GER) primarily involves issues with the digestive system, such as regurgitation of stomach contents into the esophagus. Impaired oral mucous membrane is not directly related to GER. The other nursing diagnoses are more relevant and applicable in a case of GER:
A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory interventions should the nurse plan to implement? (Select all that apply.)
- A. Clear liquids in the morning before the procedure
- B. Cathartic in the evening before the procedure
- C. Soapsuds enema the morning of the procedure
- D. Insertion of a Foley catheter before the procedure
Correct Answer: A
Rationale: Clear liquids in the morning before the procedure: It is important for the child to have clear liquids before the procedure to ensure proper hydration and to help with visualization during the urography.
Newborns are highly susceptible to infection as a result of:
- A. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM).
- B. diminished nonspecific and specific immunity.
- C. increased humoral immunity.
- D. overwhelming anti-inflammatory response.
Correct Answer: B
Rationale: Newborns are highly susceptible to infection due to their diminished nonspecific and specific immunity. Nonspecific immunity includes physical barriers such as intact skin and mucous membranes, as well as components of the innate immune system like phagocytes and complement proteins. Specific immunity refers to the adaptive immune response involving B and T cells. In newborns, both these arms of the immune system are not fully developed or mature, leading to increased susceptibility to infections. Additionally, newborns have lower levels of immunoglobulins like IgA and IgM compared to adults, further contributing to their vulnerability to infections.
A first-time mother brings in her 5-day-old baby for a well-child visit. The baby weighs 7 lb 5 oz, down from 7 lb 10 oz at discharge. The nurse's best response is:
- A. I will notify the doctor about this weight loss.
- B. Newborns can lose up to 10% of their birth weight and regain it by 2 weeks of age.
- C. I can tell you are a first-time mother; don't worry.
- D. Maybe the baby isn't getting enough milk. How often are you feeding?
Correct Answer: B
Rationale: A small weight loss is normal in the first week of life; infants typically regain their birth weight by 2 weeks.
A 3-week-old neonate is brought to the emergency department because of a three-day history of intermittent vomiting. His mother reports that he has not urinated for eight hours. On physical examination, his eyes are sunken. Which of the following will MOST likely require correction before surgery is performed?
- A. Hypochloremia
- B. Hyperkalemia
- C. Hypernatremia
- D. N/A
Correct Answer: A
Rationale: Hypochloremia is often associated with dehydration and metabolic alkalosis, which may need correction before surgery.