Nokea
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
- A. Hypoalbuminemia with hemoconcentration
- B. Volume overload with hemodilution
- C. Metabolic acidosis
- D. Lack of erythropoeitin factor
Correct Answer: B
Rationale: A reduced hematocrit (Hct) in a client with deep partial-thickness burns can be primarily caused by volume overload with hemodilution. In patients with burns, there is an initial shift of fluid from the intravascular space to the interstitial space, leading to a decreased intravascular volume. In response to this hypovolemia, there is an increased release of antidiuretic hormone (ADH) and aldosterone, resulting in retention of water and sodium. This volume overload leads to hemodilution, where the proportion of red blood cells to plasma decreases, causing a reduction in hematocrit levels. This scenario is a common occurrence in clients with burn injuries and helps explain the reduced hematocrit in this client.
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Mrs. Adams is scheduled for an intravemous pyelogram (IVP). Nurse Aura wpould be most concerned if the patient makes which of the following comments or statements?
- A. "I take Senokot (laxative) daily."
- B. "I often feel like my bladder is full even after voiding."
- C. "My whole face turns red when I eat mussels."
- D. "I experience headaches every 2 weeks."
Correct Answer: A
Rationale: Nurse Aura would be most concerned about the patient's statement regarding taking Senokot daily because laxatives can affect kidney function and urine production, which are important considerations during an intravenous pyelogram (IVP). Laxatives can lead to dehydration and electrolyte imbalances, which may affect the results and safety of the IVP procedure. It is crucial for the patient to disclose any medications or substances they are taking that could impact kidney function or urine production prior to undergoing the IVP. The other statements are not directly related to the IVP procedure or potential complications.
Austin, age 6 months, has six teeth. How should the nurse interpret this finding?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier-than-normal tooth eruption
Correct Answer: A
Rationale: The eruption of teeth in infants typically begins around 6 months of age, with the lower central incisors being the first to appear. Having six teeth at 6 months old is within the normal range of tooth eruption for infants. The average time frame for infants to have their first teeth is between 4 to 7 months, so Austin's situation falls within that range. There is no cause for concern or interpretation of the finding as unusual or dangerous in this scenario.
Which screening test is a neonatal nurse likely to use to detect developmental dysplasia of the hip (DDH)?
- A. Barlow's maneuver
- B. Pavlik's maneuver
- C. Gower's maneuver
- D. Allis's maneuver
Correct Answer: B
Rationale: Neonatal nurses are likely to use Pavlik's maneuver to detect developmental dysplasia of the hip (DDH) in newborns. Pavlik's maneuver is a technique used to diagnose, treat, and manage DDH in infants. It involves positioning the infant's hips in a flexed and abducted position to help stabilize the hip joint and promote proper development. This technique is gentle and non-invasive, making it suitable for screening infants for hip dysplasia. Other maneuvers listed, such as Barlow's, Gower's, and Allis's maneuvers, are different techniques used to assess hip stability or alignment and are not specific to DDH screening in newborns.
Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
- A. To reduce the risk of seizures before and after surgery
- B. To avoid intraoperative complications
- C. To reduce cerebral edema
- D. To prevent postoperative vomiting
Correct Answer: A
Rationale: The correct statement justifying the administration of the prescribed anticonvulsant phenytoin to a client before intracranial surgery is "To reduce the risk of seizures before and after surgery." Patients undergoing intracranial surgery are at an increased risk of seizures due to the manipulation of the brain tissue and the potential for increased intracranial pressure during the procedure. Administering an anticonvulsant like phenytoin before surgery helps reduce the risk of seizures both during the surgery and in the postoperative period. This proactive approach not only protects the patient from the potential harm associated with seizures but also contributes to a smoother recovery process.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.