Nokea
The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?
- A. Potassium 7.5 mEq/L
- B. Sodium 131 mEq/L
- C. Arterial pH 7.34
- D. Hematocrit 52%
Correct Answer: A
Rationale: Hyperkalemia (7.5 mEq/L) is life-threatening, risking arrhythmias, and requires immediate reporting. Hyponatremia (B), slightly low pH (C), and elevated hematocrit (D) are less urgent in early burn care.
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A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Sternal and subcostal retractions
- D. Decreased respirations
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?
- A. Reinforcing the need for a balanced diet
- B. Encouraging the client to drink 16 ounces of fluid with each meal
- C. Telling the client to eat a diet low in fiber
- D. Instructing the client to limit his intake of fruits and vegetables
Correct Answer: A
Rationale: A balanced diet with adequate fiber (soluble for IBS) helps regulate bowel function and reduce IBS symptoms. High fluid intake with meals may exacerbate symptoms, low-fiber diets can worsen constipation, and limiting fruits/vegetables is not advised.
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
- A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake
- B. Purse the lips and take quick, short breaths approximately 18-20 times/min
- C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series
- D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
Correct Answer: A
Rationale: This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.