Nokea
The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.
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Which of the following would the nurse teach the adolescent is a complication of corticosteroids used in the treatment of JRA?
- A. Fat loss.
- B. Adrenal stimulation.
- C. Immune suppression.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Corticosteroids, such as prednisone, are commonly used in the treatment of juvenile rheumatoid arthritis (JRA) to reduce inflammation and pain. However, one of the complications associated with corticosteroid use is immune suppression. Corticosteroids can suppress the immune system by reducing the activity and effectiveness of white blood cells, making individuals more susceptible to infections. It is important for healthcare providers, including nurses, to educate adolescents and their families about the risks and possible complications of corticosteroid therapy, including immune suppression.
Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
- A. To determine the clients response to the therapy
- B. To flush out the infectious microorganisms from the urinary tract
- C. To determine the location of discomfort
- D. To detect any evidence of changes#
Correct Answer: B
Rationale: A nurse measures the intake and output and recommends a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis primarily to help flush out the infectious microorganisms from the urinary tract. Pyelonephritis is a bacterial infection of the kidneys and urinary tract, and increasing fluid intake can help dilute the urine and increase urine output, which may help wash out and eliminate the infectious microorganisms causing the infection. Adequate hydration also helps the kidneys function optimally in eliminating waste and toxins from the body. Therefore, maintaining a high fluid intake is crucial in the management of pyelonephritis to support the body's natural defense mechanisms and aid in recovery.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse in charge anticipates that the doctor will order which laboratory test?
- A. Total iron-binding capacity
- B. Hemoglobin
- C. Total protein
- D. Serum transferrin
Correct Answer: C
Rationale: Total protein is a laboratory test that is commonly ordered to assess the nutritional status of an individual. In the case of a child with poor nutritional status and weight loss, assessing the total protein levels can help in diagnosing a negative nitrogen balance. Total protein levels may decrease in individuals with inadequate protein intake, malnutrition, or negative nitrogen balance. Monitoring total protein levels can provide valuable information about the child's nutritional status and help guide further interventions to improve their overall health and well-being.
Prenatal changes associated with maternal diabetes include all the following EXCEPT
- A. shorter birth length
- B. lower neonatal neurodevelopmental status
- C. reduced milk production of the most times
- D. increased neonatal learning problems
Correct Answer: C
Rationale: Reduced milk production is not directly associated with maternal diabetes.
A worried mother of a 4-year-old boy describing attacks of inconsolable crying episodes. The MOST appropriate action is
- A. reassures her that this is a normal phenomenon of temper tantrum
- B. seek more history regarding other skills and developmental domains
- C. refer her to pediatric psychiatry
- D. investigate social issues of the family
Correct Answer: A
Rationale: Temper tantrums are common at this age and often do not indicate pathology.