Nokea
An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, 'The swelling occurred for no reason, and it keeps getting worse.' The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?
- A. A decreased urinary output and flank pain
- B. A fever of over 103°F occurring over the last 2-3 weeks
- C. Rashes covering the palms of the hands and the soles of the feet
- D. Headaches, malaise, or sore throat
Correct Answer: D
Rationale: Urinary tract symptoms are not commonly associated with Lyme disease. A fever of 103°F is not characteristic of Lyme disease. The rash that is associated with Lyme disease does not appear on the palms of the hands and the soles of the feet. Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.
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The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's first stage of labor
- C. Decreases the time of the client's first stage of labor
- D. Prolongs the client's third stage of labor
Correct Answer: B
Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.
The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?
- A. Sluggish bowel sounds
- B. Pain and tenderness at the umbilicus
- C. Passage of small amount of liquid stool
- D. Increasing abdominal girth
Correct Answer: D
Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
The client with hyperemesis gravidarum is at risk for developing:
- A. Respiratory alkalosis without dehydration
- B. Metabolic acidosis with dehydration
- C. Respiratory acidosis without dehydration
- D. Metabolic alkalosis with dehydration
Correct Answer: B
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to dehydration and loss of stomach acid resulting in metabolic acidosis. The dehydration exacerbates the acid-base imbalance.