Nokea
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
- A. The fracture heals without complications.
- B. The caregivers verbalize safe and effective home care.
- C. The child maintains normal joint and muscle integrity.
- D. The child displays age-appropriate developmental behaviors.
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.
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The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
- A. Daily weight
- B. Calorie count
- C. Skinfold measurement
- D. Serum prealbumin level
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.
The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
- A. A kink in the tube
- B. The client fighting the ventilator
- C. Increased secretions in the airway
- D. A cuff leak in the endotracheal tube
- E. The client biting on the endotracheal tube
- F. The ventilator tubing disconnecting from the endotracheal tube
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
- A. Weight loss of 4 ounces and dry, peeling skin
- B. Blood glucose level of 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) before the last feeding
- C. Breast-feeding for 20 minutes or more, with strong sucking
- D. High-pitched cry, drinking 10 to 15mL of formula per feeding
Correct Answer: D
Rationale: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
The nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
- A. My child can return to school for full days 2 weeks after discharge.
- B. I should allow my child to play inside but omit outside play at this time.
- C. I should have my child avoid crowds and people for 2 weeks after discharge.
- D. I should call the primary health care provider if my child develops faster or harder breathing than normal.
Correct Answer: A
Rationale: The child may return to school the third week after hospital discharge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the primary health care provider.
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further instruction?
- A. I can use an ophthalmic analgesic ointment at night if I have eye discomfort.
- B. I do not need to be concerned about spreading this infection to others in my family.
- C. I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye.
- D. I should perform saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present.
Correct Answer: B
Rationale: Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime because discomfort becomes more noticeable when the eyelids are closed. When purulent discharge is present, saline eye irrigations or applications of warm compresses to the eye may be necessary before instilling the medication.