Nokea
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin.
- B. Wash the skin with water and pat dry.
- C. Cover the area with a petroleum gauze.
- D. Apply an occlusive dressing to the site.
Correct Answer: B
Rationale: Clean, dry skin is required before hyperbaric oxygen therapy to prevent infection and ensure effective oxygen delivery. Lotions, petroleum, or dressings can interfere or pose fire risks.
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A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Abstract thinking
- B. Ability to focus and concentrate thoughts
- C. Judgment
- D. Memory
Correct Answer: B
Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Thready pulse
- B. Irregular pulse
- C. Tachycardia
- D. Bradycardia
Correct Answer: D
Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: A
Rationale: Chest drainage of 150 mL/hour post-CABG suggests significant bleeding, requiring immediate reporting to prevent hypovolemia. Confusion, pallor, and low urine output are less urgent.
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.