Nokea
For the teenager recovering from an appendectomy, which nursing measure is most appropriate to prevent respiratory complications during the postoperative period?
- A. Administer a bronchodilator by inhalation.
- B. Administer oxygen by nasal cannula.
- C. Give the child a corticosteroid.
- D. Have the child use an incentive spirometer.
Correct Answer: D
Rationale: Using an incentive spirometer encourages deep breathing, preventing atelectasis and pneumonia, common respiratory complications post-surgery due to immobility and anesthesia.
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The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?
- A. An extra supply of sterile dressing
- B. An endotracheal tube and oxygen supply
- C. Equipment to administer pain medication
- D. Additional bags of I.V. fluid
Correct Answer: B
Rationale: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
Which of the following test is used in screening for Down's syndrome:
- A. Ca 125.
- B. Carcino embryonic antigen CAE.
- C. Triple screening including β HCG,AFP,serum estriol.
- D. FSH,LH.
- E. Thyroid hormone.
Correct Answer: C
Rationale: The triple screen (β-hCG AFP serum estriol) is used in the second trimester to screen for Down syndrome. Other tests are not relevant for this purpose.
An infant had four wet diapers during the 8-hour shift. The weight of a dry diaper is 15 g. The four wet diapers weighed 30 g, 24 g, 21 g, and 25 g. What amount in milliliters should the nurse record for the total 8-hour urine? _______ mL (Record your answer as a whole number.)
Correct Answer: 40
Rationale: Subtract dry diaper weight (15 g): 30–15=15 g 24–15=9 g 21–15=6 g 25–15=10 g. Total: 15+9+6+10=40 g equaling 40 mL urine output.
Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.