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A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.
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The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
- A. Begin administering supplemental oxygen.
- B. Document the findings according to facility policies.
- C. Notify the child's primary health care provider immediately.
- D. Reassess the respiratory rate, rhythm, and depth in 15 minutes.
Correct Answer: B
Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.
A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client's recovery is normal?
- A. Pink-colored lochia
- B. White-colored lochia
- C. Serosanguineous lochia
- D. Dark red-colored lochia
Correct Answer: D
Rationale: When checking the perineum, the lochia is monitored for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is dark red. Options 1, 2, and 3 are not the expected characteristics of lochia at this time period.
The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? Select all that apply.
- A. Fatigue
- B. Anorexia
- C. Weakness
- D. Low-grade fever
- E. Joint deformities
- F. Joint inflammation
Correct Answer: A,B,C,D,F
Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that primarily affects the synovial joints. Early manifestations include fatigue, anorexia, weakness, joint inflammation, low-grade fever, and paresthesia. Joint deformities are late manifestations.
The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information should the nurse give the client about the postsurgical needs?
- A. You will need to undergo chemotherapy after surgery.
- B. You will need to wear an abdominal binder after surgery.
- C. You will not need any special long-term treatment after surgery.
- D. You will need to take daily hormone replacements beginning after the surgery.
Correct Answer: D
Rationale: The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy require permanent replacement of adrenal hormones. Options 1, 2, and 3 are inaccurate statements regarding this surgery.