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The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
- A. Obtain arterial blood gases (ABGs)
- B. Increase oxygen rate from 30% to 50%
- C. Suction the tracheostomy tube
- D. Medicate for anxiety and pain
Correct Answer: C
Rationale: C: Suctioning clears potential airway obstructions causing desaturation. A: ABGs are secondary if suctioning resolves distress. B: Increasing oxygen is ineffective with an occluded airway. D: Medication doesn't address airway issues.
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The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?
- A. Keep the infant fully clothed to prevent chilling and hypothermia.
- B. Cover the infant's eyes with eye shields to prevent retinal damage.
- C. Limit the number of feedings to reduce the number of soiled diapers.
- D. Discontinue the phototherapy if the infant develops a mild skin rash.
Correct Answer: B
Rationale: B: Eye shields protect retinas from phototherapy light. A: Clothing reduces skin exposure, hindering bilirubin conversion. C: Increased feedings aid bilirubin excretion. D: Mild rashes are harmless and don't warrant discontinuation.
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
- A. Encourage foods high in vitamin C such as orange juice
- B. Premedicate with analgesics prior to dressing changes
- C. Monitor pedal pulses and capillary refill of affected extremity
- D. Use hydrogen peroxide for cleaning of the ulcer wound
- E. Turn and reposition the client every 1 to 2 hours
- F. Elevate the extremity on pillows, keeping the heel off the pillow
Correct Answer: A,B,C,E,F
Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.
Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct Answer: A
Rationale: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.
Which of the following statements is true about syphilis?
- A. The cause and mode of transmission is unclear
- B. There is no known cure for the disease
- C. When the primary lesion heals, the disease is cured
- D. Syphilis can be cured with a course of antibiotic therapy
Correct Answer: D
Rationale: Syphilis is an acute and chronic treponemal disease that can be cured with antibiotics, such as a single IM dose of long-acting penicillin G (benzathine penicillin) for primary, secondary, or early latent syphilis. The cause and transmission (sexual contact) are clear, and healing of the primary lesion does not indicate a cure without treatment.
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.