Nokea
The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.
- A. Place infant in an open crib.
- B. Maintain intravenous site and fluids.
- C. Plan time for parents to hold the infant.
- D. Position infant in a side-lying position with a blanket roll to support the viscera.
- E. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.
Correct Answer: B,D,E
Rationale: Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. The infant is kept nothing by mouth (NPO) so that the intravenous (IV) site and fluids are maintained. The infant should be placed in a side-lying position and the viscera supported with a blanket roll to prevent vascular compromise to a torqued intestine. Before surgery, the exposed viscera should be kept covered with sterile moistened saline gauze and plastic wrap. Thermoregulation is critical, so the infant should be placed in a warmer crib, not an open crib. The movement of the infant should be minimized, so parents are not allowed to hold the infant before surgery.
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A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
- A. Call his family to come in to visit with him.
- B. Notify his health care provider of the change.
- C. Place respiratory resuscitation equipment in the client's room.
- D. Check for advancing levels of paresthesia.
- E. Perform ankle pumps to increase circulation and relieve numbness.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (B), monitoring for respiratory involvement with resuscitation equipment (C), and ongoing assessment of paresthesia (D). Family visits and ankle pumps are not priorities.
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
- A. Supine.
- B. Prone.
- C. Fowler's position.
- D. Trendelenburg position.
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
- A. Sodium 135 mEq/L (135 mmol/L)
- B. Sodium 145 mEq/L (145 mmol/L)
- C. Potassium 3.1 mEq/L (3.1 mmol/L)
- D. Potassium 5.0 mEq/L (5.0 mmol/L)
Correct Answer: C
Rationale: Hypokalemia can result from long-term use of casanthranol, which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal range for sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The remaining options all suggest normal values.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Monitoring the client for at least 15-30 minutes after starting a transfusion is critical to detect acute reactions like hemolysis or allergic responses.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
- A. This doctor has been on our staff for 20 years.'
- B. I know you are worried, but the doctor has an excellent reputation.'
- C. You always have an option to change. Tell me about your concerns.'
- D. I take my own children to this doctor.'
Correct Answer: C
Rationale: Acknowledging the mother's concerns and offering to discuss them respects her autonomy and opens a dialogue to address specific issues, potentially resolving misunderstandings or facilitating a change if needed.