Nokea
Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve:
- A. Repacking the nose.
- B. Returning the client to surgery.
- C. Enforcing bed rest with the head of the bed elevated.
- D. Administering high-dose corticosteroid therapy.
Correct Answer: C
Rationale: Bed rest with head elevation reduces pressure on the surgical site, promoting healing of a CSF leak.
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A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
- A. PaCO2.
- B. HCO3.
- C. PaO2.
- D. pH
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive 4 year old child. Which therapeutic action should the nurse take?
- A. Draw a "magic circle" on the area before the injection.
- B. Have another nurse hold down the child.
- C. Apply EMLA cream to the area immediately before the injection.
- D. Administer the medication right after the child's nap.
Correct Answer: D
Rationale: Administering after a nap can reduce anxiety and discomfort in a child, as they are likely to be calmer.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such as fever, chills, and fatigue, which are expected adverse effects. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typically associated with this medication.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.