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The nurse is caring for a 4-year-old client who suffered second and third-degree burns to the chest, abdomen, and legs. Vital signs: P 117, RR 44, BP 90/60, pulse oximetry reading 88% on room air. The nurse should initially
- A. obtain a prescription for intravenous fluid replacement
- B. prepare the client for airway intubation
- C. perform wound care to the burned areas
- D. review the client's laboratory data
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension indicate hypovolemia from burns, requiring immediate IV fluid replacement.
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The nurse is preparing to administer prescribed intravenous phenytoin to a client with epilepsy. Prior to starting the infusion, the nurse should
- A. establish continuous cardiac monitoring
- B. obtain the serum peak level prior to infusion
- C. initiate continuous electroencephalography (EEG) monitoring
- D. insert an indwelling urinary catheter
Correct Answer: A
Rationale: Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is necessary during infusion.
The nurse is caring for a child immediately following a nephrectomy in the postanesthesia care unit (PACU). Which assessment should the nurse initially perform?
- A. pain level
- B. peripheral vascular access device
- C. surgical incision
- D. vital signs
Correct Answer: D
Rationale: Vital signs are the initial priority in the PACU to assess stability post-nephrectomy.
The nurse is caring for a client who has been prescribed prednisone. Which of the following statements, if made by the nurse, would be correct?
- A. This medication may make you gain weight.
- B. It is best to take this medication in the morning with food.
- C. If you have pain, it is okay to take ibuprofen.
- D. Your blood pressure may decrease while taking this medication.
- E. You may experience mood changes while on this medicine.
Correct Answer: A, B, E
Rationale: Prednisone can cause weight gain, should be taken in the morning with food to reduce GI upset, and may cause mood changes. Ibuprofen should be avoided due to increased GI risk, and prednisone may increase, not decrease, blood pressure.
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
- A. Diaphoresis
- B. Sudden weight gain
- C. No wet diapers
- D. Hypoxia
- E. Increased appetite
Correct Answer: A, B, C, D
Rationale: Diaphoresis, sudden weight gain, no wet diapers, and hypoxia are early signs of heart failure in children.
The nurse is caring for a client who is prescribed IV heparin. The client is prescribed 12 units/kg/hr. The client weighs 92 kgs (202.4 lbs). The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should the client receive?
Correct Answer: 11 mL/hr
Rationale: Calculation: 92 kg x 12 units/kg/hr = 1104 units/hr. Heparin concentration: 25,000 units/250 mL = 100 units/mL. 1104 units / 100 units/mL = 11.04 mL/hr, rounded to 11 mL/hr.