Nokea
A 5-year old is admitted to the hospital with pneumonia. Her orders include chest physiotherapy, mist tent, and inhalation with Mucomyst (acetylcysteine). Which of the following measures should be included in her care?
- A. Telling her to breathe in through her nose and breathe out through her mouth
- B. Applying lotion to the exposed parts of her body
- C. Checking her clothing and linen frequently for dampness
- D. Obtaining a rectal temperature q 4 hours
Correct Answer: C
Rationale: Checking clothing and linen for dampness is necessary due to the mist tent, which can cause moisture buildup, leading to discomfort or skin issues.
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A four-year-old child with sickle cell anemia.
The nurse is aware that which of the following statements, if made by the parents of a four-year-old child with sickle cell anemia, indicates a need for further teaching?
- A. When my daughter complains of pain, I give her baby aspirin.'
- B. I try to keep my daughter away from people with infections.'
- C. I sometimes have to give my daughter some of her Demerol for pain.'
- D. I encourage my daughter to drink a lot of water.'
Correct Answer: A
Rationale: Strategy: 'Need for further teaching' indicates you are looking for an incorrect behavior. (1) correct-aspirin can cause a hemorrhage during a sickle cell crisis (2) important for a sickle cell client to prevent sickling crisis (3) reflects appropriate use of medication to decrease the client's pain (4) important for a sickle cell client to prevent sickling crisis
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-gastrectomy complication. Options A, C, and D are normal.
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urine output of 30 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-nephrectomy requiring immediate evaluation. Options B, C, and D are expected or normal: incision pain is typical, urine output 30 mL/hour is adequate for one kidney, and blood pressure 130/80 mmHg is stable.
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.