Nokea
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses' notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: A temperature of 101°F after cardiac surgery in a young child, especially 72 hours post-surgery, is a concerning finding that should be reported to the physician. This elevated temperature could indicate infection or another complication following the surgery. It is important for the physician to evaluate the child's condition and determine the appropriate course of action. Simply recording the temperature on nurses' notes or keeping the child warm with blankets is not adequate management in this situation. Applying a hypothermia blanket would also not be appropriate as the child is already febrile. The priority in this scenario is to report the findings to the physician for further assessment and intervention.
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Which is characteristic of newborns whose mothers smoked during pregnancy?
- A. Large for gestational age
- B. Preterm, but size appropriate for gestational age
- C. Growth retardation in weight only
- D. Growth retardation in weight, length, and head circumference
Correct Answer: D
Rationale: Newborns whose mothers smoked during pregnancy often display growth retardation in weight, length, and head circumference. Maternal smoking is associated with intrauterine growth restriction, leading to reduced size parameters at birth. This can result in newborns being smaller in weight, length, and head circumference compared to newborns of mothers who did not smoke during pregnancy. Smoking during pregnancy can have negative effects on the developing fetus, contributing to various health risks and growth abnormalities in newborns.
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: A
Rationale: Toni's response of minimizing her visual problems, talking about pursuing advanced degrees, asking about full-time job opportunities in nursing, and mentioning her desire to have more children despite her current health situation may suggest inappropriate euphoria characteristic of the disease process. Inappropriate euphoria can be a sign of an altered mental state that is not in line with the reality of the situation. It is important for healthcare providers to recognize such emotional responses as they may indicate underlying mental health issues or the need for further assessment and support.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.