Nokea
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
- A. An audible respiratory grunt
- B. Slight increase in the respiratory rate
- C. Arterial blood pH increases to ≥ 7.35
- D. Fine inspiratory crackles heard over both lungs
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
You may also like to solve these questions
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
- A. Her reasons for staying are complex. She can leave only when she is ready and can be safe.'
- B. I know it is frustrating to work with clients who don't follow our advice.'
- C. I need to do you have her again and have another chance.'
- D. These women almost never leave for good because of their emotional and financial dependency.'
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client?
- A. Anemia
- B. Hypertension
- C. Iron intoxication
- D. Bleeding tendencies
Correct Answer: B
Rationale: The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
The nurse is caring for a client with a ventricular shunt for hydrocephalus. Which finding requires immediate reporting?
- A. Clear drainage from the incision
- B. Mild headache
- C. Temperature of 98.6°F (37°C)
- D. Pupils equal and reactive
Correct Answer: A
Rationale: Clear drainage from a shunt incision may indicate cerebrospinal fluid leakage, a serious complication requiring immediate reporting.
A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.