Nokea
The nurse is preparing to administer eardrops to an infant. The nurse should plan to proceed by taking which step to assure the appropriate instillation of the medication?
- A. Pull down and back on the auricle, and direct the solution onto the eardrum.
- B. Pull up and back on the earlobe, and direct the solution toward the wall of the ear canal.
- C. Pull up and back on the auricle, and direct the solution toward the wall of the ear canal.
- D. Pull down and back on the auricle, and direct the solution toward the wall of the ear canal.
Correct Answer: D
Rationale: The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the nurse pulls down and back on the auricle. The wrist of the dominant hand is rested on the infant's head. The medication is administered by aiming it at the wall of the ear canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal.
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The nurse is caring for a client scheduled to undergo a renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
- A. Prothrombin time: 15 seconds
- B. Potassium: 3.8 mEq/L (3.8 mmol/L)
- C. Serum creatinine: 1.2 mg/dL (106 mcmol/L)
- D. Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L)
Correct Answer: A
Rationale: Postprocedure hemorrhage is a complication after renal biopsy. Because of this, prothrombin time is assessed before the procedure. The normal prothrombin time range is 11 to 12.5 seconds. The nurse ensures that these results are available and reports abnormalities promptly. Options 2, 3, and 4 identify normal values. The normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); the normal serum creatinine is 0.5 to 1.2 mg/dL (44 to 106 mcmol/L); and the normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L).
The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse should include which interventions in the plan? Select all that apply.
- A. Changing the client's position often
- B. Clamping the chest tube intermittently
- C. Maintaining the collection chamber below the client's waist
- D. Adding water to the suction control chamber as it evaporates
- E. Taping the connection between the chest tube and the drainage system
Correct Answer: A,C,D,E
Rationale: Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.
A primary health care provider prescribes 1000 mL of normal saline to infuse at 100 mL/hour. The drop factor is 10 drops/mL. The nurse should set the flow rate at how many drops per minute?
Correct Answer: 17
Rationale: It will take 10 hours for 1000 mL to infuse at 100 mL/hour (1000 mL ÷ 100 mL = 10 hour × 60 min = 600 min). Next, use the intravenous (IV) flow rate formula. Formula: Total volume × Drop factor ÷ Time in minutes. 1000 mL × 10 Drops/mL = 10,000 ÷ 600 min = 16.6, or 17 Drops/minute.