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The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving?
- A. Edema of the hands and feet
- B. Urine output of 3 mL/kg/hour
- C. Presence of a systolic murmur
- D. Respiratory rate between 60 and 70 breaths per minute
Correct Answer: B
Rationale: RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid, which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Therefore, normal urination is an early sign that the neonate's respiratory condition is improving (normal urinary output is 2 to 5 mL/kg/hour). Edema of the hands and feet occurs within the first 24 hours after the development of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress.
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The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse should include which priority action in the plan?
- A. Monitor intake and output.
- B. Assess the tissue at the surgical site.
- C. Monitor the area for numbness or tingling.
- D. Assess the complete blood cell count results.
Correct Answer: C
Rationale: Arthroscopy provides an endoscopic examination of the joint and is used to diagnose and treat acute and chronic disorders of the joint. The priority nursing action is to monitor the affected area for numbness or tingling, which could indicate neurovascular compromise.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
- A. Equal bilateral chest expansion
- B. Respiratory rate of 22 breaths per minute
- C. Diminished breath sounds on the affected side
- D. Few scattered wheezes, unchanged from baseline
Correct Answer: C
Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
- A. Identifies that the tube is draining normally
- B. Assesses the tube to locate a possible occlusion
- C. Auscultates the lungs for appropriate bilateral expansion
- D. Assists the client with frequent coughing and deep breathing
Correct Answer: B
Rationale: After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
- A. Loud wheezing
- B. Wheezing on expiration
- C. Noticeably diminished breath sounds
- D. Increased displays of emotional apprehension
Correct Answer: C
Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced.