Nokea
A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.
You may also like to solve these questions
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
- A. Notify the physician to obtain further orders.
- B. Mark the dressing and continue to monitor.
- C. Check the dressing for the presence of glucose with a Dextrostik.
- D. No action is necessary because some drainage is expected.
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
- A. What is the most appropriate response by the nurse to a young adult patient exhibiting attention-seeking behavior?
- B. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- C. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- D. Ignore the patient when she exhibits attention-seeking behavior.
- E. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings should the nurse report immediately?
- A. Absence of bowel sounds.
- B. Mild abdominal distension.
- C. Pain at the incision site.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.
After receiving an annual influenza immunization, a client develops symptoms suggestive of Guillain-Barré syndrome. Which symptom is associated with Guillain-Barré syndrome?
- A. Paresthesia and weakness of the lower extremities
- B. Hyperactive deep tendon reflexes
- C. Emotional lability
- D. Flapping tremors of the hand and feet
Correct Answer: A
Rationale: Guillain-Barré syndrome causes paresthesia and weakness in the lower extremities , progressing upward. Reflexes are hypoactive (B is incorrect). Emotional lability and tremors are not typical.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results should the nurse report immediately?
- A. Creatinine 2.0 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates nephrotoxicity, a serious gentamicin side effect. Options B, C, and D are normal.