Nokea
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: Loss of consciousness. This indicates anoxia, which may lead to death, requiring immediate reporting.
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The nurse is talking with the parent of a pediatric client who had a cast applied to the right arm 30 minutes ago. Which of the following statements by the parent would require follow-up?
- A. I understand that my child may feel tingling or burning underneath the cast for the first few days.
- B. I can use a hair dryer to blow cool air underneath the cast if my child experiences itching.
- C. I will call the clinic if my child experiences pain that is not relieved with medication.
- D. I should keep my child's arm elevated while resting for the first few days.
Correct Answer: A
Rationale: Tingling or burning may indicate neurovascular compromise or pressure on nerves, requiring immediate evaluation, not dismissal as normal.
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
- A. Assist the client with using a bedpan
- B. Check circulation and sensation of the extremities
- C. Perform range-of-motion exercises
- D. Report changes in skin integrity
- E. Turn and reposition the client in bed
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (A), perform range-of-motion exercises (C), report skin changes (D), and reposition the client (E). Checking circulation and sensation (B) requires nursing assessment skills.
When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?
- A. Clamp the tube close to the client's chest until a new chest drainage unit is set up
- B. Notify the health care provider
- C. Place the distal end of the chest tube into a bottle of sterile saline
- D. Position the client on the left side
Correct Answer: C
Rationale: Placing the distal end of the chest tube in sterile saline maintains a water seal, preventing air from entering the pleural space until a new drainage unit is prepared.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.