Nokea
When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?
- A. Avoid administration of oxygen at high levels for extended periods.
- B. Increase oxygen flow rate if the child is still tachypneic.
- C. Reduce oxygen levels gradually after symptoms improve.
- D. Humidify the oxygen to prevent drying of mucous membranes.
Correct Answer: A
Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.
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A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?
- A. Maintain the client NPO during the diuresis phase.
- B. Evaluate daily serial renal laboratory studies for progressive elevations.
- C. Observe the urine character for sedimentation and cloudy appearance.
- D. Monitor for the onset of polyuria greater than 150 ml/hour.
Correct Answer: B
Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
- A. Review the staff nurse job description to ensure that it is clear, accurate, and current.
- B. Conduct regular meetings to clarify roles.
- C. Increase communication between team members.
- D. Provide additional training for new nurses.
Correct Answer: A
Rationale: The correct answer is A: Review the staff nurse job description to ensure that it is clear, accurate, and current. By ensuring that job descriptions are clear and up-to-date, nurse-managers can reduce ambiguity and confusion about roles and responsibilities. Choice B, conducting regular meetings to clarify roles, may help but may not address the root cause of ambiguity. Choice C, increasing communication between team members, is important but may not specifically target role ambiguity. Choice D, providing additional training for new nurses, is valuable but may not directly address role ambiguity among existing staff.
A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods.
- B. Report increased bruising or bleeding.
- C. Stop medication if a cough develops.
- D. Limit intake of leafy green vegetables.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?
- A. Perform an otoscopic examination
- B. Measure the child's abdominal girth
- C. Collect a urine specimen for routine urinalysis
- D. Obtain a blood specimen for serum electrolytes
Correct Answer: C
Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.
A client with a history of chronic heart failure is admitted with shortness of breath. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Hemoglobin level
Correct Answer: B
Rationale: Corrected Rationale: In a client with chronic heart failure, serum potassium levels should be closely monitored to assess for hyperkalemia, which can worsen heart failure. Monitoring serum sodium levels is not the priority in this case. Serum creatinine level monitoring is more related to kidney function than heart failure. Hemoglobin levels are important but not the primary concern when assessing heart failure exacerbation.