Nokea
A nurse is caring for a 4-year-old child diagnosed with leukemia who is admitted with myelosuppression.
- A. "Provide a diet high in carbohydrates."'
- B. "Monitor rectal temperature every 4 hr."'
- C. "Use lemon or glycerin swabs for oral care."'
- D. "Inspect the skin daily for lesions."'
Correct Answer: D
Rationale: The correct answer is D: "Inspect the skin daily for lesions." This is important because myelosuppression can lead to decreased platelets, increasing the risk of skin lesions and bleeding. Monitoring the skin daily can help detect any lesions early and prevent complications.
A: Providing a high-carbohydrate diet is not directly related to managing myelosuppression.
B: Monitoring rectal temperature is important but not directly related to skin lesion detection.
C: Using lemon or glycerin swabs for oral care is important for mucositis, not skin lesions.
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Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitor oxygen saturation and administer pain medication.
- B. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
- C. Perform a sterile vaginal examination and assess breath sounds.
- D. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery. Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively. Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure. Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
A nurse is caring for a client who is 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
- A. To estimate fetal weight
- B. To locate a pocket of fluid
- C. To determine multiparity
- D. To pre-screen for fetal anomalies
Correct Answer: B
Rationale: The correct answer is B: To locate a pocket of fluid. Before performing an amniocentesis procedure, it is essential to locate a pocket of amniotic fluid to ensure the safety of the fetus during the procedure. This is crucial to avoid accidentally puncturing the fetus or placenta. An ultrasound helps in visualizing the amniotic fluid pocket and guiding the needle insertion accurately.
Incorrect Choices:
A: To estimate fetal weight - Estimating fetal weight is not a primary reason for preparing the client for an ultrasound before amniocentesis.
C: To determine multiparity - Multiparity (number of pregnancies) does not directly impact the need for an ultrasound before an amniocentesis.
D: To pre-screen for fetal anomalies - While ultrasounds can detect anomalies, the primary purpose before an amniocentesis is to locate the amniotic fluid pocket, not screen for anomalies.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
- A. Give the child a stuffed animal and car with rubber wheels to play with.
- B. "Give the child a stuffed animal and car with rubber wheels to play with."'
- C. "Change the bedding and the child's clothing frequently or as often as needed."'
- D. "Tuck the bottom of the tent under the mattress on three sides,leaving one side open so the child can look out."'
Correct Answer: C
Rationale: The correct answer is C. Changing the bedding and the child's clothing frequently promotes comfort by ensuring cleanliness and preventing skin irritation. This action also maintains the child's safety by reducing the risk of infections and skin breakdown. Giving a stuffed animal and a car with rubber wheels (Choice A) may pose a choking hazard. Tucking the bottom of the tent under the mattress on three sides (Choice D) may restrict airflow and increase the risk of suffocation.
A nurse is monitoring a 6-month-old infant who is diagnosed with pneumonia. The nurse observes an absence of respirations and peripheral cyanosis. After determining unresponsiveness, which of the following is the next nursing action?
- A. Look listen and feel for normal breathing.
- B. Give two rescue breaths.
- C. Position the infant to open the airway.
- D. Immediately call for assistance.
Correct Answer: C
Rationale: The correct answer is C: Position the infant to open the airway. For an unresponsive infant with absent respirations and cyanosis, the priority is to open the airway to facilitate breathing. Positioning the infant with a head tilt-chin lift maneuver helps prevent airway obstruction, allowing for adequate oxygenation. This step should be taken before providing rescue breaths or calling for assistance. Choices A, B, and D are not the immediate priority in this situation. A: Looking, listening, and feeling for normal breathing is not appropriate when the infant is unresponsive with absent respirations. B: Giving rescue breaths is not effective if the airway is obstructed. D: Calling for assistance can be done after ensuring the airway is open.
A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention?
- A. Monitor the oxygen saturation every 4 hr.
- B. Teach the parents dietary restrictions regarding protein.
- C. Weigh the child daily and record intake and output.
- D. Counsel the parents about the need for follow-up.
Correct Answer: C
Rationale: The correct answer is C: Weigh the child daily and record intake and output. This intervention is crucial in monitoring fluid balance and kidney function in a child with acute glomerulonephritis. Daily weights help assess for fluid retention, while intake and output measurements help evaluate kidney function. Edema, hypertension, and gross hematuria are key symptoms of this condition, indicating the need for close monitoring.
Choice A is incorrect because monitoring oxygen saturation is not directly related to the management of acute glomerulonephritis. Choice B is also incorrect as dietary restrictions regarding protein are not the priority in this situation. Choice D is incorrect as counseling about follow-up is important but not the most immediate intervention needed.