Nokea
The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?
- A. Client with emphysema expecting discharge
- B. Bronchitis client receiving IV antibiotics
- C. Bronchitis client with edema and neck vein distention
- D. COPD client with abnormal PO2
Correct Answer: C
Rationale: Edema and neck vein distention in a bronchitis client suggest right heart failure or cor pulmonale, requiring immediate assessment. Emphysema discharge (A), antibiotics (B), and abnormal PO2 (D) are less urgent.
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A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should:
- A. Explain that a microwave should never be used to warm the baby's bottles.
- B. Tell the mother that microwaving is the best way to prevent bacteria in the formula.
- C. Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
- D. Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.
Correct Answer: A
Rationale: Microwaving baby bottles can cause uneven heating, leading to burns, so it should be avoided; warming under running water or in a bottle warmer is safer.
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
- A. The diameter of the trachea is much smaller in children than in adults.
- B. The tongue is proportionally smaller in children than in adults.
- C. The pediatric airway is more rigid than that of the adults.
- D. The length of the pediatric airway is longer in children than in adults.
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
- A. A blood pressure reading of 130/70 with a 5-lb weight loss
- B. No side effects from antihypertensive medication and an accurate pill count
- C. No evidence of increased left ventricular hypertrophy on chest x-ray
- D. Serum blood levels of the antihypertensive medication within therapeutic range
Correct Answer: A
Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Polyuria and polydipsia
- C. Irritability relieved by feeding formula
- D. Hypothermia and azotemia
Correct Answer: B
Rationale: Anemia and vomiting are not cardinal signs of diabetes insipidus. Polyuria and polydipsia are the cardinal signs of diabetes insipidus. Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
The client is diagnosed with a pleural effusion. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Thoracentesis
- C. Bronchoscopy
- D. Nebulizer treatment
Correct Answer: B
Rationale: Thoracentesis is used to remove fluid from a pleural effusion, relieving respiratory distress. Chest tubes are for pneumothorax or persistent effusions, bronchoscopy is diagnostic, and nebulizers are irrelevant.