Nokea
The parents of a 6-year-old recently diagnosed with asthma should be taught that the symptom of acute episodes of asthma is due to which physiological response?
- A. Inflammation of the mucous membrane & bronchospasm
- B. Increased mucus production and bronchoconstriction
- C. Allergic reactions and hyperventilation
- D. Airway narrowing and decreased lung capacity
Correct Answer: A
Rationale: The correct answer is A: Inflammation of the mucous membrane & bronchospasm. Acute asthma episodes are primarily caused by inflammation of the airways and bronchospasm, which lead to airway obstruction. Increased mucus production and bronchoconstriction (Choice B) are part of the physiological responses in asthma but do not directly cause acute episodes. Allergic reactions and hyperventilation (Choice C) are related to asthma triggers and responses but are not the direct causes of acute episodes. Airway narrowing and decreased lung capacity (Choice D) are consequences of inflammation and bronchospasm but do not explain the physiological response leading to acute asthma episodes.
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What nursing intervention is particularly indicated for the second stage of labor?
- A. Providing pain medication to increase the client's tolerance of labor
- B. Assessing the fetal heart rate and pattern for signs of fetal distress
- C. Monitoring effects of oxytocin administration to help achieve cervical dilation
- D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved
Correct Answer: D
Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)
- A. 42
Correct Answer: A
Rationale: To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute. Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct Answer: A
Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.
A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?
- A. capillary glucose
- B. urine specific gravity
- C. Serum calcium
- D. white blood cell count
Correct Answer: C
Rationale: The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.
The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?
- A. Measure the client's cardiac output
- B. Assess neurological status q15 min
- C. Collect a blood specimen for serum potassium
- D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min
Correct Answer: B
Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.