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An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
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A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:
- A. Explain that the medication should be discontinued during illness.
- B. Arrange for the pump to be refilled in the hospital.
- C. Reschedule the pump refill for the day of discharge.
- D. Instruct caregivers to call for a refill when the low-volume alarm sounds.
Correct Answer: B
Rationale: Arranging for the pump to be refilled in the hospital ensures continuous therapy, as interrupting baclofen can cause withdrawal symptoms.
After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifies which of the following as the site for the aspiration?
- A. Right lateral side of the right wrist.
- B. Middle of the chest.
- C. Distal end of the thigh.
- D. Back of the hipbone.
Correct Answer: D
Rationale: Bone marrow aspiration is typically performed at the iliac crest (hipbone). Other sites are incorrect.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.
A 12-year-old child has had a traumatic head injury from playing in a football game. He is admitted to the emergency department and transferred to the pediatric intensive care unit. He has an I.V. of dextrose 5% in water at a 'keep-open' rate and nasal oxygen at 2 L/minute. The nurse is assessing the child at the beginning of the shift (11:00 p.m.) and reviews the Glasgow Coma Scale flow sheet. The nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. What should the nurse do first?
- A. Notify the physician.
- B. Administer pain medication.
- C. Increase oxygen flow.
- D. Document the findings.
Correct Answer: A
Rationale: A Glasgow Coma Scale score indicating pain response, incomprehensible sounds, and abnormal flexion (approximately 6-8) suggests severe neurological impairment, warranting immediate physician notification.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.