Nokea
After assisting with a vaginal delivery, what should the nurse do to prevent heat loss via conduction in the newborn?
- A. Wrap the newborn in a blanket.
- B. Close the doors to the delivery room.
- C. Dry the newborn with a warm blanket.
- D. Place the newborn on a warm crib pad.
Correct Answer: D
Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Warming the crib pad will assist in preventing hypothermia by conduction. Radiation occurs when heat from the newborn radiates to a colder surface. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth will prevent hypothermia via evaporation.
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The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action?
- A. Inhale deeply.
- B. Breathe normally.
- C. Breathe out forcefully.
- D. Take a deep breath and hold it.
Correct Answer: D
Rationale: The client is instructed to take a deep breath and hold it for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space. Therefore, options 1, 2, and 3 are incorrect.
A client scheduled for pneumonectomy tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?
- A. They are generally removed after 36 to 48 hours.
- B. Not every lung surgery requires chest tubes to be used.
- C. They usually remain in place for a full week after surgery.
- D. Your type of surgery rarely requires chest tubes to be inserted after surgery.
Correct Answer: D
Rationale: Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies.
The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) should plan care by implementing which intervention?
- A. Beginning thrombolytic therapy
- B. Placing the client on continuous cardiac monitoring
- C. Infusing intravenous (IV) fluid at a rate of 150 mL per hour
- D. Administering oxygen at a rate of 6 L per minute by nasal cannula
Correct Answer: B
Rationale: Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the primary health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure that there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 L per minute unless otherwise prescribed.
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.
A low dose of ondansetron is prescribed for a client receiving chemotherapy. The nurse anticipates that the primary health care provider will prescribe the medication by which route?
- A. Oral
- B. Intranasal
- C. Intravenous
- D. Subcutaneous
Correct Answer: C
Rationale: Ondansetron is an antiemetic used to control nausea, vomiting, and motion sickness. It is available for administration by the oral, intramuscular (IM), or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed in the client receiving chemotherapy. The IM route may be used when the medication is used as an adjunct to anesthesia. Option 1 should not be used in clients who are nauseated. Options 2 and 4 are not routes of administration of this medication.