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Which action should the nurse implement as part of care for a client after a bone biopsy?
- A. Monitoring the vital signs once per day.
- B. Keeping the area in a dependent position.
- C. Administering intramuscular opioid analgesics.
- D. Monitoring the site for swelling, bleeding, or hematoma formation.
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.
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The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?
- A. Bed rest
- B. Intravenous fluids
- C. Supplemental oxygen
- D. Meperidine hydrochloride
Correct Answer: D
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone. These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. The remaining options are appropriate prescriptions for treating vaso-occlusive pain crisis.
The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
- A. Prone
- B. Supine
- C. Supine with the neck flexed
- D. Prone with the neck hyperextended
Correct Answer: D
Rationale: The prone position with the neck hyperextended improves the child's breathing. Based on that information, none of the remaining options are appropriate positions.
A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?
- A. Document the finding.
- B. Tell the client that the FHR is fast.
- C. Consult with the primary health care provider.
- D. Recheck the FHR with the client in the standing position.
Correct Answer: C
Rationale: The FHR should be between 120 and 160 beats/min. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the primary health care provider. The FHR would be documented, but option 3 is the appropriate action. The nurse would not tell the client that the FHR is fast at this point in time. Option 4 is an inappropriate action.
The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?
- A. It sounds as if the hepatitis may be worsening.'
- B. It is necessary to isolate the child from others in the home.'
- C. The jaundice may appear to get worse before it begins to resolve.'
- D. You need to bring the child to the health care clinic to see the primary health care provider.'
Correct Answer: C
Rationale: The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child's condition, specifically changes in neurological status, bleeding, and fluid retention. Based on this information, the statements in the remaining options are incorrect.
A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101°F (38.3°C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?
- A. Notify the primary health care provider.
- B. Administer an acetaminophen suppository.
- C. Encourage the client to cough and deep breathe.
- D. Administer a bronchodilator prescribed on an as-needed basis.
Correct Answer: A
Rationale: The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty with managing saliva or coughing or choking while eating. Because the client has developed a complication that requires medical intervention, the most appropriate action is to contact the primary health care provider. The remaining options are not related to the management of aspiration.