Nokea
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: For clients diagnosed with hyperparathyroidism, it is important to restrict sodium in the diet. High sodium intake can worsen calcium loss from the bones and increase the risk of kidney stones, both of which are concerns for individuals with hyperparathyroidism. Therefore, it is crucial to advise the client to limit their sodium intake to help manage their condition effectively.
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A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
- A. Wrap the neonate warmly and place her in an open crib
- B. Administer an oral glucose feeding of 10% dextrose in water
- C. Increase the temperature setting on the radiant warmer
- D. Obtain an order for IV fluid administration
Correct Answer: A
Rationale: The neonate is likely experiencing hypothermia with an axillary temperature below the normal range for a newborn. The best immediate action is to prevent further heat loss by wrapping the neonate warmly to maintain body temperature. Placing the neonate in an open crib will allow for better monitoring without the heat source of the radiant warmer. It is important to continue monitoring the neonate's temperature closely to ensure it returns to the normal range.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.
Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
- A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
- B. Encourage fluids to flush dye from the patient's system.
- C. Monitor the patient for return to consciousness.
- D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D
Rationale: After a bronchoscopy procedure, it is essential to check for the presence of a gag reflex before allowing the patient to drink. This is crucial to prevent aspiration, as the gag reflex helps protect the airway by triggering swallowing and preventing foreign material from entering the lungs. Allowing the patient to drink without assessing the gag reflex could lead to serious complications such as aspiration pneumonia. Therefore, checking for the gag reflex is an appropriate nursing action to ensure the safety and well-being of the patient after a bronchoscopy.
Which of the following guidekines does not observe surgical asepisi in the operating room?
- A. sterile articles may touch other sterile articles or surface and remain sterile
- B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
- C. whenever a sterile barrier is breached, the area must be considered contaminated
- D. sterile drapes are used to create a sterile field
Correct Answer: A
Rationale: This statement is incorrect and does not observe surgical asepsis in the operating room. In surgical asepsis, it is crucial that sterile articles do not touch other sterile articles or surfaces to prevent contamination. Any contact between sterile items or surfaces can lead to the transfer of microorganisms, compromising the sterility of the environment. Maintaining a sterile field is essential to prevent surgical site infections and ensure the safety of the patient undergoing the procedure.
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.