Nokea
Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
- A. A syringe that contains a preservative
- B. A heparinized syringe and a bag of ice
- C. A heparinized syringe and a preservative
- D. A syringe that contains a preservative and a bag of ice
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.
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The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?
- A. Involuntary movements affecting the legs, arms, and face
- B. Inflammation of all parts of the heart, primarily the mitral valve
- C. Tender, painful joints, especially in the elbows, knees, ankles, and wrists
- D. Red skin lesions that start as flat or slightly raised macules, usually over the trunk, and that spread peripherally
Correct Answer: B
Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Option 1 describes chorea. Option 3 describes polyarthritis. Option 4 describes erythema marginatum.
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
- A. Monitoring for hearing loss
- B. Monitoring intake and output (I&O)
- C. Repositioning the child every 2 hours
- D. Providing a quiet environment with dimmed lighting
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
- A. Fluid restriction
- B. Administering diuretics
- C. Increased sodium intake
- D. Intravenous (IV) replacement of fluid losses
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
- A. Lie flat and lift the legs straight up.
- B. Lie on the right side and then roll to the left side while the arms are held overhead.
- C. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides.
- D. Stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides.
Correct Answer: D
Rationale: To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.