Nokea
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
- A. The mother cleans the ears and then moves to the eyes and the face.
- B. The mother begins to wash the newborn infant by starting with the eyes and face.
- C. The mother washes the arms, chest, and back followed by the neck, arms, and face.
- D. The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.
Correct Answer: B
Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant's neck should be washed because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last.
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A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
- A. Delirium
- B. Muscle rigidity
- C. Hypotension
- D. Pinpoint rash
Correct Answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
- A. Do nothing; this is a normal response
- B. Strip the tubing to remove any clots
- C. Place a clamp on the tube near the client's chest
- D. Remove the collection chamber and connect the tubing to a new device
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.
The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year?
- A. risk of coronary heart disease is the same as that of a nonsmoker
- B. carbon monoxide level in blood drops to normal
- C. risk of dying from lung cancer is about half that of a smoker's
- D. risk of having a stroke is reduced to that of a nonsmoker's
Correct Answer: B
Rationale: Within 24 hours of quitting smoking, carbon monoxide levels drop to normal. Other benefits (A, C, D) take longer (5-15 years for heart disease, 10 years for lung cancer, 5-10 years for stroke risk). Thus, B is the correct benefit within one year.
A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
- A. Keep the client in an upright position at all times
- B. Auscultate lung sounds every shift and after feedings
- C. Maintain suction equipment at the client's bedside
- D. Instruct the client about how to perform swallowing exercises
Correct Answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
- A. Place the client in the Trendelenburg position
- B. Contact the physician for an order for antibiotics
- C. Administer oxygen therapy
- D. Decrease his IV rate
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.