Nokea
The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
- A. Rinsing the incision with sterile water after feeding
- B. Cleaning the incision only when serous exudate forms
- C. Rubbing the incision gently with a sterile cotton-tipped swab
- D. Replacing the Logan bar carefully after cleaning the incision
Correct Answer: A
Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision.
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The nurse is assigned to care for a client experiencing hypertonic labor contractions. The nurse plans to conserve the client's energy and promote rest by performing which intervention?
- A. Keeping the TV or radio on to provide distraction
- B. Assisting the client with breathing and relaxation techniques
- C. Keeping the room brightly lit so the client can watch her monitor
- D. Avoiding uncomfortable procedures such as intravenous infusions or epidural anesthesia
Correct Answer: B
Rationale: Breathing and relaxation techniques aid the client in coping with the discomfort of labor and conserving energy. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs.
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for?
- A. Cyanosis with accompanying pallor
- B. Diffuse crackles and rhonchi on chest auscultation
- C. Increase in respiratory rate from 18 to 30 breaths per minute
- D. Haziness or 'white-out' appearance of lungs on chest radiograph
Correct Answer: C
Rationale: ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or 'white-out' appearance in the later stages.
The primary health care provider prescribes 250 mg of amikacin sulfate every 12 hours. How many milliliters (mL) should the nurse prepare to administer one dose? Refer to the figure.
Correct Answer: 5
Rationale: Use the medication calculation formula. Formula: (Desired × mL) / Available = mL per dose. (250 mg × 2 mL) / 100 mg = 5 mL per dose.
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply.
- A. Headache
- B. Tachycardia
- C. Hypertension
- D. Apprehension
- E. Distended neck veins
- F. A sense of impending doom
Correct Answer: A,B,D,F
Rationale: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
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.