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A nurse has determined that a newborn's respiratory breathing is within a normal range. How should the nurse document this finding?
- A. Irregular, abdominal, 30 to 60 breaths/min
- B. Regular, abdominal, 25 to 35 breaths/min
- C. Regular, noisy, 35 to 45 breaths/min
- D. Irregular, quiet, 45 to 55 breaths/min
Correct Answer: B
Rationale: A newborn with normal respiratory breathing would typically exhibit regular breathing patterns, with abdominal movements indicating effective diaphragmatic breathing. The normal respiratory rate for a newborn is considered to be 25 to 35 breaths per minute. Therefore, documenting the newborn's respiratory breathing as "Regular, abdominal, 25 to 35 breaths/min" would accurately represent a normal finding.
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The dietary practice that will help a client reduce the dietary intake of sodium is
- A. Increasing the use of dairy products
- B. Using an artificial sweetener in coffee
- C. Avoiding the use of carbonated beverages
- D. Using catsup for cooking and flavoring food
Correct Answer: C
Rationale: The dietary practice that will help a client reduce the dietary intake of sodium is avoiding the use of carbonated beverages. Carbonated beverages, such as sodas, contain high amounts of sodium that can contribute to increased sodium intake. By avoiding carbonated beverages, the client can effectively reduce their overall sodium consumption. Increasing the use of dairy products, using artificial sweeteners in coffee, and using catsup for cooking and flavoring food do not specifically address the reduction of sodium intake in the same way that avoiding carbonated beverages does.
Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:
- A. 48 hours
- B. 2 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: Compartment syndrome is a serious condition that results from increased pressure within a closed anatomical space (compartment), leading to decreased circulation to local neuromuscular structures. In the case of a casted elbow, if compartment syndrome is left untreated and persists for more than 24 hours, irreversible damage can occur. This is due to the compromised blood flow causing tissue ischemia, which can lead to permanent nerve and muscle damage. Therefore, it is crucial for healthcare providers to monitor for signs and symptoms of compartment syndrome and intervene promptly to prevent long-term complications.
Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?
- A. once a month after menstruation
- B. every ether month after menstruation
- C. once a month before menstruation
- D. every other month before menstruation
Correct Answer: A
Rationale: Performing monthly breast self-examination (BSE) after menstruation is recommended because during this time, the breasts are less likely to be swollen or tender, which can help to ensure a more accurate examination. Engaging in BSE on a regular basis can help individuals become familiar with their breast tissue and better recognize any changes that may occur. By performing BSE monthly after menstruation, individuals can actively monitor their breast health and potentially detect any abnormalities or signs of breast cancer at an early stage.
Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation?
- A. Aortic stenosis (AS)
- B. Coarctation of aorta
- C. Patent ductus arteriosus (PDA)
- D. Tetralogy of Fallot
Correct Answer: D
Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four primary abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis, less blood reaches the lungs to be oxygenated, resulting in deoxygenated blood entering the systemic arterial circulation. This leads to cyanosis, which is often referred to as "Tet spells" in these patients. Cyanosis is the bluish discoloration of the skin and mucous membranes caused by the presence of deoxygenated hemoglobin. The other conditions listed do not typically result in deoxygenated blood entering the systemic arterial circulation and causing cyanosis.
A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this?
- A. Prevent infection
- B. Stimulate appetite
- C. Detect evidence of edema
- D. Ensure compliance with prophylactic antibiotic therapy
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by the presence of edema due to loss of protein in the urine. One of the nursing goals in managing a child with minimal change nephrotic syndrome receiving high doses of prednisone is to monitor for the development or worsening of edema. Detecting evidence of edema is important as it can help in assessing the effectiveness of treatment, such as monitoring the response to prednisone therapy and adjusting the treatment plan accordingly. Monitoring for edema can also help in preventing complications associated with fluid overload, such as hypertension and respiratory distress. Therefore, detecting evidence of edema is an appropriate nursing goal in this scenario.