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When teaching umbilical cord care to a new mother, the nurse would include which information?
- A. Apply peroxide to the cord with each diaper change
- B. Cover the cord with petroleum jelly after bathing
- C. Keep the cord dry and open to air
- D. Wash the cord with soap and water each day during a tub bath
Correct Answer: C
Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.
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A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: Monitoring temperature every 4 hours is crucial in detecting signs of a urinary tract infection in a postoperative client. An increase in temperature can indicate the presence of an infection, and early identification is essential for prompt treatment. While coughing and deep breathing (Option A) are beneficial for postoperative clients to prevent respiratory complications, they are not directly related to detecting UTI. Splinting the incision (Option C) is important for incisional care but does not specifically help in detecting UTI. Irrigating tubes (Option D) should only be done as ordered by the healthcare provider and is not a routine measure for detecting UTI.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: Edrophonium HCL is ordered to rule out cholinergic crisis caused by possible overdose of neostigmine. In myasthenia gravis, patients are normally given neostigmine to help improve muscle strength by prolonging the effect of acetylcholine at the neuromuscular junction. However, if too much neostigmine is given, it can lead to a cholinergic crisis characterized by excess stimulation at the neuromuscular junction. Edrophonium HCL is a fast-acting drug that can help differentiate between a myasthenic crisis (worsening of symptoms due to under-dosing of anti-cholinesterase medication like neostigmine) and a cholinergic crisis (worsening of symptoms due to over-dosing). By administering edrophonium HCL, the healthcare provider can observe the patient's response and determine if the weakness is due to under-treatment or over-treatment with
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
- A. Self-care deficient: Bathing/hygiene
- B. Dysfunctional grieving
- C. Ineffective cerebral tissue perfusion
- D. Risk for injury
Correct Answer: C
Rationale: The nursing diagnosis that takes the highest priority for a client in a late stage of AIDS with signs of AIDS-related dementia is Ineffective cerebral tissue perfusion. This diagnosis is prioritized because AIDS-related dementia is associated with changes in brain function due to HIV affecting the brain tissues. Ensuring adequate cerebral perfusion is crucial to maintaining brain function and preventing further deterioration. Monitoring and addressing any factors that could affect cerebral perfusion, such as blood pressure, oxygenation, and circulation, are essential in managing this condition. Other nursing diagnoses are also important, but addressing ineffective cerebral tissue perfusion should be the highest priority in this situation to prevent further complications related to neurological function.
A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is "term" if which findings are assessed? (Select all that apply.)
- A. Posture with fully flexed arms and legs
- B. Arm recoil brisk
- C. Square window at 90 degrees
- D. Scarf sign of elbow crossing over the midline
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
- A. 5 seconds
- B. 10 seconds
- C. 30 seconds
- D. 60 seconds
Correct Answer: C
Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.