Nokea
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.
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A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
- A. Tell me what frightens you the most about seizures.
- B. Tylenol can prevent another seizure from occurring.
- C. Most children will never experience a second seizure.
- D. Why worry about something that you cannot control?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Change the IV solution bag.
Correct Answer: B
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.
A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development?
- A. Providing a music player
- B. Tutoring to keep the child up with schoolwork
- C. Providing a phone for calling family and friends
- D. Placing computer games, a television, and videos at the bedside
Correct Answer: B
Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.