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A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
- A. Protect the neonate's eyes from the heat lamp
- B. Monitor the neonate's temperature
- C. Warm all medications and liquids before administration
- D. Avoid touching the neonate with cold hands
Correct Answer: B
Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.
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The healthcare provider is caring for a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
- A. 3 episodes of vomiting in 1 hour
- B. Periodic crying and irritability
- C. Vigorous sucking on a pacifier
- D. No measurable voiding in 4 hours
Correct Answer: D
Rationale: The correct answer is 'No measurable voiding in 4 hours.' This finding should be reported to the healthcare provider immediately. The concern is the possibility of hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. It is crucial to monitor urinary output in pediatric patients receiving potassium-containing IV solutions to prevent electrolyte imbalances and potential complications.
Choices A, B, and C are not the most critical findings that require immediate reporting. '3 episodes of vomiting in 1 hour' may suggest a need for antiemetic therapy or further assessment of the underlying cause but does not pose an immediate risk like the potential electrolyte imbalance from decreased urinary output. 'Periodic crying and irritability' and 'Vigorous sucking on a pacifier' are common behaviors in infants and are not indicative of a critical condition that requires urgent attention in this scenario.
The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?
- A. Reprimand the child and give a 15-minute 'time out'
- B. Maintain a permissive attitude for this behavior
- C. Use patience and a sense of humor to deal with this behavior
- D. Assert authority over the child through limit setting
Correct Answer: C
Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.
The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.
A healthcare professional is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the healthcare professional to immediately discontinue this part of the assessment?
- A. The patient states, 'That sounds like it might hurt me.'
- B. There is a pulsating mass on the upper middle abdomen.
- C. The patient has black, tarry stools and anemia.
- D. The patient has had an endoscopic procedure two days prior.
Correct Answer: B
Rationale: A pulsating mass on the upper middle abdomen is indicative of a life-threatening aortic aneurysm. Palpating or percussing such an area can potentially cause the aneurysm to rupture, leading to severe internal bleeding and endangering the patient's life. Therefore, the healthcare professional should immediately discontinue the assessment to prevent any harm.\nChoice A is incorrect because the patient expressing concerns about the procedure does not necessarily indicate a life-threatening condition. Choice C describes symptoms that should be further investigated but do not pose an immediate threat during abdominal assessment. Choice D, a prior endoscopic procedure, is not a contraindication for palpation or percussion of the abdomen unless there are specific complications or conditions related to the procedure that would require caution.
What would be the most appropriate follow-up by the home care nurse for a 57-year-old male client with a hemoglobin of 10 g/dl and a hematocrit of 32%?
- A. Ask the client if he has noticed any bleeding or dark stools
- B. Tell the client to call 911 and go to the emergency department immediately
- C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
- D. Tell the client to schedule an appointment with a hematologist
Correct Answer: A
Rationale: The correct answer is to ask the client if he has noticed any bleeding or dark stools. Normal hemoglobin for males is 13.0 - 18 g/dl, and normal hematocrit for males is 42 - 52%. The values of hemoglobin and hematocrit provided for the client are below normal, indicating mild anemia. The first step for the nurse is to inquire about any signs of bleeding or changes in stools that could suggest bleeding from the gastrointestinal tract. This helps in assessing the possible cause of the low hemoglobin and hematocrit levels. The other options are not appropriate as calling 911 and going to the emergency department immediately is not warranted for mild anemia, scheduling a repeat test in 1 month delays addressing the current concern, and referring the client to a hematologist may be premature without investigating the cause of the low levels first.