Nokea
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.
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The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted?
- A. Breast engorgement
- B. Elevated white blood cell count
- C. Lochia rubra on the second day postpartum
- D. Fever over 38°C (100.4°F), beginning 2 days postpartum
Correct Answer: D
Rationale: Endometritis is a common cause of postpartum infection. The presence of fever of 38°C (100.4°F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated; thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal finding.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds?
- A. Absent
- B. Vesicular
- C. Bronchial
- D. Bronchovesicular
Correct Answer: C
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.
A client is diagnosed with cholecystitis. The nurse reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.
- A. Dyspepsia
- B. Dark stools
- C. Light-colored and clear urine
- D. Feelings of abdominal fullness
- E. Rebound tenderness in the abdomen
- F. Upper abdominal pain that radiates to the right shoulder
Correct Answer: A,D,E,F
Rationale: Cholecystitis is an inflammation of the gallbladder. Manifestations include dyspepsia; feelings of abdominal fullness; rebound tenderness (Blumberg's sign); upper abdominal pain or discomfort that can radiate to the right shoulder; pain triggered by a high-fat meal; clay-colored stools, dark urine, and possible steatorrhea; anorexia, nausea, and vomiting; eructation; flatulence; fever; and jaundice.
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement?
- A. Unkinking the tubing
- B. Assessing for an air leak
- C. Documenting that the lung has reexpanded
- D. Documenting that the lung has not yet reexpanded
Correct Answer: D
Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate occlusion of the tubing or that the lung has reexpanded. Excessive bubbling in the water seal chamber indicates that an air leak is present.
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
- A. Serum insulin level
- B. Heel stick blood glucose
- C. Rh and ABO blood typing
- D. Indirect and direct bilirubin levels
Correct Answer: B
Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth.