Nokea
A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?
- A. Occult blood in the stool
- B. Abdominal distention
- C. Elevated urine specific gravity
- D. Hyperactive bowel sounds
Correct Answer: C
Rationale: Step 1: Elevated urine specific gravity indicates increased concentration of urine, a sign of dehydration.
Step 2: In dehydration, the body conserves water, leading to concentrated urine.
Step 3: The child's symptoms (increased stools, liquid consistency, fever, vomiting) suggest dehydration.
Step 4: Other choices (A: occult blood, B: distention, D: hyperactive bowel sounds) are not specific to dehydration.
Summary: Elevated urine specific gravity is key as it directly reflects dehydration, unlike the other choices which are not specific indicators of dehydration.
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The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct Answer: B
Rationale: The correct answer is B: A 35-year-old with lupus erythematosus. This client should be recommended for transfer to the antepartal unit because lupus erythematosus is an autoimmune disorder that can affect pregnancy outcomes. The antepartal unit is better equipped to provide specialized care for high-risk pregnancies, which would be necessary for a client with lupus.
A: A 45-year-old with chronic hepatitis B - Hepatitis B does not directly impact pregnancy outcomes and does not require transfer to the antepartal unit.
C: A 19-year-old diagnosed with rubella - Rubella is a viral infection that can be harmful during pregnancy, but the client should be managed in a different unit specialized in infectious diseases.
D: A 25-year-old with herpes lesions of the vulva - Herpes lesions of the vulva can be managed in the medical-surgical unit and do not necessarily require transfer to the antepartal unit unless there
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct Answer: A
Rationale: The correct action for the nurse to take first is to apply a sterile saline dressing to the wound. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented.
Summary of Incorrect Choices:
B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority.
C: Administering pain medication does not address the primary concern of protecting the exposed bowel.
D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.
The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
- A. Monitor serum calcium levels
- B. Obtain a baseline electrocardiogram
- C. Implement seizure precautions
- D. Encourage a low-protein diet
Correct Answer: C
Rationale: The correct answer is C. Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? This question is crucial because seizures can be a common symptom of a brain tumor. By asking about seizures, the nurse can gather important information about the client's condition and potential complications. Seizures can also indicate the location and size of the tumor.
A: When did your symptoms first begin? This question is important, but seizures are more specific to brain tumor assessment.
B: Can you describe the pain and how it feels? Pain can vary and may not always be present with a brain tumor.
C: Do you have any changes in vision? Vision changes can occur but may not be as indicative of a brain tumor as seizures.
In summary, asking about seizures is crucial for immediate assessment and management of a client with a brain tumor, as it can provide valuable insight into the client's condition.