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The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take?
- A. Prepare for defibrillation.
- B. Continue to monitor the rhythm.
- C. Prepare to administer lidocaine hydrochloride.
- D. Notify the primary health care provider immediately.
Correct Answer: B
Rationale: As an isolated occurrence, the PVC is not life-threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the primary health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.
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Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply.
- A. Obtaining a chest x-ray
- B. Obtaining a throat culture
- C. Monitoring pulse oximetry
- D. Maintaining a patent airway
- E. Providing humidified oxygen
- F. Administering antipyretics and antibiotics
Correct Answer: A,C,D,E,F
Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.
The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement?
- A. Allowing the client to complete the exercise program
- B. Interrupting the client and weigh the client immediately
- C. Interrupting the client and offer to take the client for a walk
- D. Telling the client that he or she is not allowed to exercise rigorously
Correct Answer: C
Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety.
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the child's risk for condition-related injury?
- A. Check the anterior fontanel for bulging and the sutures for widening each day.
- B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration.
- C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.
- D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air.
Correct Answer: C
Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.