Nokea
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Keep the umbilical area moist with Vaseline until the stump falls off.
- B. Keep the umbilical area covered at all times with the diaper.
- C. Clean the umbilical cord with alcohol at each diaper change.
- D. Clean the umbilical cord daily with soap and water during the bath.
Correct Answer: C
Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
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A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
- A. 7-Nov
- B. 10-Nov
- C. 7-May
- D. 10-May
Correct Answer: D
Rationale: Using Nägele's rule (LMP - 3 months + 7 days + 1 year), August 3 leads to an estimated delivery date of May 10.
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. Blowing air under the cast using a hair dryer on cool setting often relieves itching.
- B. Slide a ruler under the cast and scratch the area.
- C. Guide a towel under and through the cast and move it back and forth to relieve the itch.
- D. Gently thump on cast to dislodge dried skin that causes the itching.
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Aplastic crisis
- B. Vaso-occlusive crisis
- C. Dactylitis crisis
- D. Sequestration crisis
Correct Answer: D
Rationale: Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
- A. Careful monitoring of weight loss or gain
- B. Carefully recording amounts and types of foods ingested
- C. Keeping a strict account of the number of calories ingested
- D. Keeping a careful account of the amount of pancreatic enzymes ingested
Correct Answer: A
Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.
Which aminophylline level is associated with signs of toxicity?
- A. 5 micrograms/mL
- B. 10 micrograms/mL
- C. 20 micrograms/mL
- D. 25 micrograms/mL
Correct Answer: D
Rationale: Aminophylline levels above 20 micrograms/mL are toxic, causing symptoms like nausea, tachycardia, or seizures. 25 micrograms/mL is well above the therapeutic range (10-20).