Nokea
The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.
- A. Check the client for abdominal distention and constipation
- B. Examine the catheter for kinks and obstructions
- C. Contact the client's health care provider
- D. Place the client in a side-lying position
- E. Flush the tubing with dialysate
Correct Answer: A,B,D
Rationale: Checking for distention/constipation (A), examining for catheter issues (B), and repositioning to a side-lying position (D) address common causes of outflow issues non-invasively.
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An 18-month old has been hospitalized six times for upper airway infections. Diagnostic studies including sweat analysis confirm the diagnosis of cystic fibrosis. Which of the following statements describes the inheritance pattern for cystic fibrosis?
- A. An affected gene is inherited from both the father and mother, who remain symptom free.
- B. Males are at risk at twice the rate as females.
- C. Autosomal recessive disorders tend to skip generations, so the children of affected parents will have children with the disorder.
- D. The disorder is transmitted by an affected gene on one of the six chromosomes.
Correct Answer: A
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring a mutated gene from both parents, who are carriers but asymptomatic.
The home health nurse is caring for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse determines the client is unresponsive and pulseless, and there are no other caregivers present. Which of the following actions should the nurse take next?
- A. Deliver 30 chest compressions.
- B. Activate the emergency response system.
- C. Locate an automated external defibrillator.
- D. Deliver 2 breaths using a bag valve device connected to the tracheostomy.
Correct Answer: B
Rationale: Activating the emergency response system ensures rapid assistance for a pulseless child, initiating the chain of survival in pediatric cardiac arrest.
The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply.
- A. Adhere to the child's home routine when possible during hospitalization
- B. Encourage parents to bring the child's favorite toy from home
- C. Have the parents step out of the room during procedures
- D. Promote a quiet sleep environment with reduced stimuli
- E. Provide a parent's shirt for the child to hold during procedures
Correct Answer: A,B,D,E
Rationale: Following the home routine (A), providing familiar toys (B), ensuring a quiet sleep environment (D), and offering a parent's shirt (E) promote comfort and security for a 6-month-old.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.