Nokea
The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
- A. Chronic vessel plaque formation
- B. Pulmonary embolism
- C. Occlusions at the vessel bifurcations
- D. Coronary artery aneurysms
Correct Answer: D
Rationale: Coronary artery aneurysms. Kawasaki disease can lead to inflammation and aneurysms in coronary arteries.
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In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
- A. Assess the brachial pulses
- B. Breathe once every 5 compressions
- C. Use both hands to apply chest pressure
- D. Compress 80-90 times per minute
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.
A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm³, RBC 5.1 ml/mm³, and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis?
- A. Risk for activity intolerance related to decrease in red cells.
- B. Risk for infection related to low white cell count.
- C. Risk for anxiety; secondary to hypoparathyroid disease.
- D. Risk for fluid volume deficit due to decreased fluid intake.
Correct Answer: B
Rationale: clients with a low WBC count are susceptible to infection
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
- A. explaining that the client will be walking with a prosthesis soon after surgery.
- B. encouraging the client to share his feelings and fears about the surgery.
- C. taking the informed consent form to the client and asking him to sign it.
- D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Correct Answer: B
Rationale: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning