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The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
- A. Assure that the oxygen is not blowing directly on the infant’s face.
- B. Place the butterfl y mobile on the outside of the hood.
- C. Immobilize the infant with restraints.
- D. Remove the hood for 10 minutes every hour.
- E. Encourage the parents to visit the child.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
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A client with a history of depression is prescribed bupropion (Wellbutrin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Seizures.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bupropion lowers the seizure threshold, and seizures are a serious side effect requiring immediate reporting.
A client with gastroesophageal reflux disease (GERD) reports chest discomfort that feels like heartburn, especially following each meal. After teaching the client to take antacids as prescribed, the nurse suggests that the client lie in which position during sleep?
- A. Prone with the head of the bed flat
- B. Supine with the head of the bed flat
- C. On the left side with the head of the bed flat
- D. With the head of the bed elevated 8 to 12 inches
Correct Answer: D
Rationale: The discomfort of reflux is aggravated by positions that allow the reflux of gastrointestinal contents. The client is instructed to remain upright for 1 to 2 hours after a meal and sleep with the head of the bed elevated to approximately 30 degrees (usually on 8- to 12-inch blocks). Lying flat will increase the episodes of reflux, resulting in chest discomfort.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to:
- A. Take NSAIDs at least three times per day.
- B. Exercise the joints at least 1 hour after taking the medication.
- C. Take antacids 1 hour after taking NSAIDs.
- D. Take NSAIDs with food.
Correct Answer: D
Rationale: Taking NSAIDs with food reduces gastrointestinal irritation and the risk of ulcers, a common side effect of these medications.
A client with schizophrenia is prescribed risperidone. Which side effect should the nurse monitor for?
- A. Weight loss.
- B. Extrapyramidal symptoms.
- C. Hypotension.
- D. Increased appetite.
Correct Answer: B
Rationale: Risperidone can cause extrapyramidal symptoms, such as tremors or rigidity, due to dopamine receptor blockade.
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
- A. Pale pink
- B. Bright red
- C. Dark pink
- D. Tea-colored
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.