Nokea
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
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Contributing features to renal osteodystrophy include:
- A. Hypophosphataemia
- B. Hyperparathyroidism
- C. Increased loss of calcium in the kidney
- D. Hypoalbuminaemia
Correct Answer: B
Rationale: Hyperparathyroidism is a key contributor to renal osteodystrophy due to secondary hyperparathyroidism in chronic kidney disease.
The patient experiences a headache and is unable to move the left side of his body. The most likely cause is
- A. embolic stroke
- B. cerebral thrombosis
- C. cerebral abscess
- D. moyamoya disease
Correct Answer: A
Rationale: Embolic stroke is a common complication of cyanotic congenital heart disease.
The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, “Why do my child’s fingertips look like that?†On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Clubbing of the fingers develops in response to chronic hypoxia.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses’ notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.
The following are examples of acquired heart disease. Select all that apply.
- A. Infective endocarditis
- B. Coarctation of the aorta
- C. Rheumatic fever (RF)
- D. Cardiomyopathy
Correct Answer: C
Rationale: Acquired heart diseases include conditions that develop after birth, such as infective endocarditis, rheumatic fever, cardiomyopathy, and Kawasaki disease. Coarctation of the aorta and transposition of the great vessels are congenital heart defects.