Nokea
The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femurs?
- A. Abduction
- B. Adduction
- C. Flexion
- D. Extension
Correct Answer: A
Rationale: The correct answer is A: Abduction. The use of the Pavlik harness is to maintain the hips in abduction for 4 to 6 months to treat developmental hip dysplasia. This position helps in stabilizing the hip joint and promoting proper growth and development. Choices B, C, and D are incorrect because the Pavlik harness specifically aims to hold the child's femurs in abduction, not adduction, flexion, or extension.
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The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?
- A. When the course of antibiotics is complete
- B. When a negative CNS culture is obtained
- C. When the antibiotics have been initiated for 24 hours
- D. When the child has no symptoms of the disease
Correct Answer: C
Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct Answer: A
Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.
The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct Answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
A client who had surgery yesterday is becoming increasingly anxious. The client's respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum pH. Which serum laboratory value should the nurse monitor first?
- A. Electrolytes.
- B. Creatinine.
- C. Blood urea nitrogen.
- D. Glucose.
Correct Answer: A
Rationale: The correct answer is A, Electrolytes. In this scenario, the client is at risk for metabolic alkalosis due to the loss of gastric secretions through the nasogastric tube. Monitoring electrolytes is crucial to assess the levels of sodium, potassium, chloride, and bicarbonate, which are important in maintaining the acid-base balance of the body. Changes in these electrolyte levels can provide valuable information about the client's fluid status and acid-base balance. Creatinine, blood urea nitrogen, and glucose levels are important parameters to monitor in different situations but are not the priority in this case of potential metabolic alkalosis.
A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?
- A. Restrain the child in the tent and notify the health care provider.
- B. Increase the oxygen concentration in the tent.
- C. Take the child out of the tent and into the playroom.
- D. Ask the mother for help in comforting the child.
Correct Answer: B
Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.