Nokea
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
You may also like to solve these questions
The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have nausea and no appetite.
- C. I have a headache sometimes.
- D. I take my medication with food.
Correct Answer: B
Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.
An adult is thought to have myasthenia gravis. The nurse knows that which test is most likely to be ordered for the client?
- A. Lumbar puncture
- B. CT scan
- C. Cerebral angiogram
- D. Edrophonium (Tensilon) test
Correct Answer: D
Rationale: The edrophonium test, which temporarily improves muscle strength in myasthenia gravis, confirms diagnosis by enhancing neuromuscular transmission, unlike imaging or lumbar puncture.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Pain at the incision site.
- C. Vaginal bleeding of 50 mL.
- D. Absence of bowel sounds.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious complication post-hysterectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, minimal vaginal bleeding, and absent bowel sounds are normal on day 1.
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
- A. Severe depression
- B. Violent behavior
- C. Respiratory distress
- D. Convulsions
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
A five-year-old girl after the application of a cast to the left arm.
After the cast is applied, the nurse should
- A. petal the edges of the cast to prevent irritation.
- B. elevate the client's left arm on two pillows.
- C. apply cool, humidified air to dry the cast.
- D. ask the client to move her fingers to maintain mobility.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct-minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast