Nokea
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
- A. Dependent edema
- B. Diminished distal pulse
- C. Coolness and pallor of the skin
- D. Presence of warm areas on the cast
Correct Answer: D
Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
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Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
- A. Are you sleeping well at home?
- B. Did you get much sleep last night?
- C. May we talk about how you've been sleeping?
- D. Do you think you get enough sleep on a nightly basis?
Correct Answer: C
Rationale: Option 3 is a question and provides the client the opportunity to express thoughts and feelings. The remaining options could lead to a one-word answer that would not provide thorough assessment data. Additionally, one night of sleep may not tell the nurse how the pattern has been over time.
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
- A. Presence of a cephalhematoma
- B. Infant blood type of O negative
- C. Birth weight of 8 pounds 6 ounces
- D. A negative direct Coombs' test result
Correct Answer: A
Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that there are no maternal antibodies on fetal erythrocytes.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the child's risk for condition-related injury?
- A. Check the anterior fontanel for bulging and the sutures for widening each day.
- B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration.
- C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.
- D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air.
Correct Answer: C
Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.