Nokea
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
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A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?
- A. Decreasing hematocrit and increasing urine volume
- B. Rising hematocrit and decreasing urine volume
- C. Falling hematocrit and decreasing urine volume
- D. Stable hematocrit and increasing urine volume
Correct Answer: B
Rationale: Rising hematocrit and decreasing urine volume. A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
Ear drops have been ordered for a 10-month-old child. How should the nurse teach the mother to pull the baby's ear to straighten the ear canal?
- A. Down and back
- B. Down and forward
- C. Up and forward
- D. Up and back
Correct Answer: A
Rationale: In children under 3, pulling the ear down and back straightens the ear canal for proper ear drop administration.
The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the following findings would the nurse expect?
- A. Buffalo hump
- B. Increased muscle mass
- C. Peripheral edema
- D. Jaundice
Correct Answer: A
Rationale: Buffalo hump. With high doses of glucocorticoid, iatrogenic Cushing's syndrome develops. The exaggerated physiological action causes abnormal fat distribution which results in a moon-shaped face, an intrascapular pad on the neck (buffalo hump) and truncal obesity with slender limbs.
The client asks the clinic nurse if he should take 2,000 mg of vitamin C a day to prevent getting a cold. On which scientific rationale should the nurse base the response?
- A. Vitamin C in this dosage will help cure the common cold.
- B. This vitamin must be taken with echinacea to be effective.
- C. This dose of vitamin C is not high enough to help prevent colds.
- D. Megadoses of vitamin C may cause crystals to form in the urine.
Correct Answer: D
Rationale: Megadoses of vitamin C (>2,000 mg/day) can lead to oxalate crystal formation in urine, increasing kidney stone risk. Evidence for cold prevention is weak, and echinacea or higher doses are not supported.
The client is receiving a loop diuretic for congestive heart failure. Which medication would the nurse expect the client to be receiving while taking this medication?
- A. A potassium supplement.
- B. A cardiac glycoside.
- C. An ACE inhibitor.
- D. A potassium cation.
Correct Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss; supplements prevent hypokalemia, a common need in CHF.