Nokea
The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
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Which medication instructions should the nurse provide to a client who has been prescribed levothyroxine? Select all that apply.
- A. Monitor your own pulse rate.
- B. Take the medication in the morning.
- C. Take the medication at the same time each day.
- D. Notify the primary health care provider if chest pain occurs.
- E. Expect the pulse rate to be greater than 100 beats per minute.
- F. It may take 1 to 3 weeks for a full therapeutic effect to occur.
Correct Answer: A,B,C,D,F
Rationale: Levothyroxine is a thyroid hormone. The client is instructed to monitor her or his own pulse rate. The client is also instructed to take the medication in the morning before breakfast to prevent insomnia and to take the medication at the same time each day to maintain hormone levels. The client is told not to discontinue the medication and that thyroid replacement is lifelong. Additional instructions include contacting the primary health care provider if the rate is greater than 100 beats per minute and notifying the primary health care provider if chest pain occurs, or if weight loss, nervousness and tremors, or insomnia develops. The client is also told that full therapeutic effect may take 1 to 3 weeks and that he or she needs to have follow-up thyroid blood studies to monitor therapy.
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the cause of this client's pleural effusion?
- A. Trauma
- B. Infection
- C. Liver failure
- D. Heart failure
Correct Answer: A
Rationale: Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.
- A. Constipation
- B. Muscle twitches
- C. Negative Chvostek's sign
- D. Positive Trousseau's sign
- E. Hyperactive deep tendon reflexes
- F. Prolonged ST interval on electrocardiogram (ECG)
Correct Answer: B,D,E,F
Rationale: Hypocalcemia is a total serum calcium level less than 9 mg/dL (2.25 mmol/L). Clinical manifestations include muscle twitches, hyperactive deep tendon reflexes, positive Trousseau's sign, and prolonged ST interval on ECG. Negative Chvostek's sign and constipation are not associated with hypocalcemia.
A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.
A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take?
- A. Call the primary health care provider.
- B. Administer an opioid analgesic.
- C. Apply warm moist heat for comfort.
- D. Apply ice to minimize any developing swelling.
Correct Answer: A
Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion.