Nokea
The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
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The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw?
- A. That no action is required.
- B. The head of the bed needs to be lowered.
- C. The infant needs to be placed on NPO status.
- D. The primary health care provider should be notified immediately.
Correct Answer: A
Rationale: A bulging anterior fontanel in an infant when crying is a normal finding, as crying increases intracranial pressure temporarily. This does not indicate a pathological condition requiring immediate intervention. Lowering the head of the bed or placing the infant on NPO status is not warranted, and notifying the primary health care provider is unnecessary unless other signs of increased ICP, such as persistent bulging at rest, irritability, or lethargy, are present.
A primary health care provider prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters (mL) to administer one dose? Fill in the blank and record your answer to the nearest whole number.
Correct Answer: 14 mL
Rationale: Use the formula for calculating medication dosages. Formula: Desired × Volume / Available = mL per dose. 450 mg × 5 mL / 160 mg = 14 mL.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
The nurse is caring for a child diagnosed with Reye's syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?
- A. Protein in the urine
- B. Symptoms of hyperglycemia
- C. Increased intracranial pressure
- D. A history of a staphylococcus infection
Correct Answer: C
Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. Intracranial pressure and encephalopathy are major problems associated with Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.