Nokea
A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.
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In which type of cardiomyopathy does septal involvement occur?
- A. Congestive
- B. Dilated
- C. Hypertrophic
- D. Restrictive
Correct Answer: C
Rationale: Septal involvement is a characteristic feature of hypertrophic cardiomyopathy, where the septal wall of the heart thickens. This thickening can obstruct blood flow out of the heart, leading to complications such as arrhythmias and heart failure. This differentiates it from other types of cardiomyopathy. In congestive cardiomyopathy (choice A), the heart's chambers become enlarged and weakened, but there is no specific mention of septal involvement. Dilated cardiomyopathy (choice B) involves dilation and impaired contraction of the heart chambers, not specifically septal thickening. Restrictive cardiomyopathy (choice D) is characterized by stiffening of the heart muscle, affecting its ability to fill properly, without direct involvement of the septum.
A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?
- A. Continuous bubbling in the water seal chamber indicates an air leak.
- B. Continuous bubbling is normal and expected with a chest tube.
- C. Bubbling will stop when the lung has fully expanded.
- D. The nurse should notify the healthcare provider immediately.
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.
When administering parenteral iron, which action would be inconsistent with proper administration?
- A. Using the Z-track method
- B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
- C. Not massaging the injection site
- D. Using the deltoid muscle for administration
Correct Answer: D
Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.
A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
- A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
- B. Assessing the color of the infant's hands and feet
- C. Assessing the infant's tongue
- D. Assessing the infant's arms and legs
Correct Answer: A
Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.
A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?
- A. Encourage the client to get plenty of exercise in addition to the dietary change
- B. Provide written information about the seven warning signs of cancer
- C. Remind the client to ensure that the dairy products are fortified with Vitamin D
- D. Suggest that an increase in fruits and vegetables is more beneficial
Correct Answer: D
Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.