Nokea
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. Petrolatum be placed around the cord after the sponge bath
- B. A belly binder be applied to prevent umbilical hernia
- C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- D. The cord clamp be left on until the cord stump separates
Correct Answer: C
Rationale: Petrolatum does not allow the cord to dry and will encourage infection. Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. Frequent applications of alcohol will facilitate drying and discourage infection. The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
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A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:
- A. Deep tendon reflexes
- B. Blood pressure
- C. Urine output
- D. Tissue turgor
Correct Answer: B
Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue to monitor the vital signs
- B. Contact the physician
- C. Ask the client how he feels
- D. Ask the LPN to continue the post-op care
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
- A. Mechanical ventilation
- B. Nebulizer treatments
- C. Chest physiotherapy
- D. Antibiotic therapy
Correct Answer: A
Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.