Nokea
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
- A. Position on side or abdomen.
- B. Maintain elbow restraints in place unless she is being directly supervised.
- C. Clean suture line every shift.
- D. Offer pacifier when she cries.
Correct Answer: B
Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
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Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:
- A. Children seldom show concern about losing their hair
- B. The hair will come out gradually, and the loss will not be noticeable for some time
- C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out
- D. The parents will soon get used to seeing their children without hair, and it will no longer bother them
Correct Answer: C
Rationale: Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. A temperature elevation
- D. Dry mucous membranes
Correct Answer: B
Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (B) indicate pulmonary edema, correlating with high PAWP. BP drop (A), fever (C), and dry membranes (D) are unrelated.
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- B. Ask him to dissolve three pieces of hard candy in his mouth
- C. Have him drink 4 oz of orange juice
- D. Monitor him closely until dinner arrives
Correct Answer: C
Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
- A. Chorioamnionitis
- B. Preterm delivery
- C. Fetal distress
- D. All of the above
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client flat for meals
- C. Thicken liquids
- D. Use a straw for fluids
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in dysphagia post-stroke. Thin liquids, flat positioning, and straws increase aspiration risk.