Nokea
The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.
- A. Cradling my baby in my arms may cause stress and damage to the cast.'
- B. I will check my baby's toes several times a day to ensure that they are pink and warm.'
- C. My baby should alternate between sleeping on the stomach and back'
- D. My baby will need to have a new cast applied weekly for 5-8 weeks.'
- E. When I bathe or diaper my baby, I will be sure to keep the cast dry.'
Correct Answer: B, D, E
Rationale: Checking toes (B), weekly casts (D), and keeping the cast dry (E) are correct. Cradling (A) is safe, and alternating sleep positions (C) is not cast-related.
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The nurse enters an infant's room and observes that the infant is responsive but is choking and turning blue. Which of the following actions should the nurse take?
- A. Initiate CPR
- B. Perform abdominal thrusts.
- C. Initiate back slaps and chest thrusts.
- D. Perform a blind sweep of the infant's mouth.
Correct Answer: C
Rationale: Back slaps and chest thrusts (C) are the appropriate intervention for a choking infant. CPR (A) is for cardiac arrest, abdominal thrusts (B) are for older children, and blind sweeps (D) are dangerous.
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
- A. They can expect the child will be mentally retarded
- B. Administration of thyroid hormone will prevent problems
- C. This rare problem is always hereditary
- D. Physical growth/development will be delayed
Correct Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
Following an arteriogram, the nurse should give priority to:
- A. Allowing the client to rest
- B. Administering O2 via nasal mask
- C. Checking the ECG monitor
- D. Checking the pulses distal to the catheterization site
Correct Answer: D
Rationale: Checking distal pulses ensures adequate circulation post-arteriogram, as the procedure involves arterial puncture, which can lead to complications like hematoma or thrombosis.
The nurse should consider which of the following client reports as an indication of an allergic reaction?
- A. I can't eat broccoli or cabbage when I take my warfarin.'
- B. I get a headache when using my nitroglycerine patch.'
- C. My feet swell when I take felodipine.'
- D. My lips swell when I eat bananas or avocados.'
Correct Answer: D
Rationale: Lip swelling (D) indicates an allergic reaction to food. Broccoli/cabbage (A) affects warfarin's efficacy, headaches (B) are a side effect of nitroglycerin, and swelling (C) is a side effect of felodipine.