Nokea
A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
- A. Petrolatum jelly gauze
- B. Sterile 4 x 4 gauze pad
- C. Absorbent gauze dressing
- D. Gauze impregnated with povidone-iodine
Correct Answer: A
Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. The items in the remaining options would not be selected as the first protective layer.
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A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply.
- A. Obtaining a chest x-ray
- B. Obtaining a throat culture
- C. Monitoring pulse oximetry
- D. Maintaining a patent airway
- E. Providing humidified oxygen
- F. Administering antipyretics and antibiotics
Correct Answer: A,C,D,E,F
Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.
The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement?
- A. Allowing the client to complete the exercise program
- B. Interrupting the client and weigh the client immediately
- C. Interrupting the client and offer to take the client for a walk
- D. Telling the client that he or she is not allowed to exercise rigorously
Correct Answer: C
Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
- A. Presence of a cephalhematoma
- B. Infant blood type of O negative
- C. Birth weight of 8 pounds 6 ounces
- D. A negative direct Coombs' test result
Correct Answer: A
Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no maternal antibodies on fetal erythrocytes.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.