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A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.
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After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
- A. Breath sounds over bilateral lung fields.
- B. Carotid pulsation during compressions
- C. Deep tendon reflexes
- D. Core body temperature
Correct Answer: A
Rationale: Assessing breath sounds ensures that the endotracheal tube is properly placed and that ventilation is effective, which is critical in a cardiac arrest situation.
Treatment for congestive heart failure (CHF) in an infant began 3 days ago and has included digoxin and furosemide. The child no longer has retractions, lungs are clear, and HR is 96 beats per minute while sleeping. The nurse is confident that the child has diuresed successfully and has good renal perfusion when the nurse notes the child's urine output is:
- A. 0.5 cc/kg/hr
- B. 1 cc/kg/hr
- C. 30 cc/hr
- D. 1 oz/hr
Correct Answer: B
Rationale: Normal pediatric urine output is approximately 1 cc/kg/hr.
Of the following, the MOST common clinical sign of coarctation of the aorta in older children is
- A. cardiac enlargement
- B. notching of the inferior border of the ribs
- C. a systolic ejection click or thrill in the suprasternal notch
- D. differential blood pressure: arms > legs
Correct Answer: B
Rationale: Notching of the ribs due to collateral circulation is a classic sign of coarctation of the aorta.
Inability to do which of the following in a 20-month child is cause for concern?
- A. Speak in clear two to three word phrases
- B. Walk unaided
- C. Kick a ball
- D. Build a tower of 8 blocks
Correct Answer: B
Rationale: Inability to walk unaided by 20 months is a red flag for developmental delay. Other skills are more variable and less concerning if delayed.