Nokea
Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.
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Which nursing action is most appropriate when caring for a child experiencing a sickle cell crisis?
- A. Apply heat to the affected joints.
- B. Administer oxygen as ordered.
- C. Encourage vigorous physical activity.
- D. Provide a high-sodium diet.
Correct Answer: B
Rationale: Administering oxygen as ordered improves oxygenation, critical during a sickle cell crisis to counteract hypoxia caused by vaso-occlusion and reduced oxygen-carrying capacity.
The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?
- A. An extra supply of sterile dressing
- B. An endotracheal tube and oxygen supply
- C. Equipment to administer pain medication
- D. Additional bags of I.V. fluid
Correct Answer: B
Rationale: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.
The nurse correctly advises the adolescent that the brace has to be worn during which time period?
- A. At all times except when bathing
- B. At least 8 hours each day
- C. At night while sleeping
- D. At all times, without exception
Correct Answer: A
Rationale: The Milwaukee brace is typically worn 23 hours a day, except during bathing, to effectively correct scoliosis by maintaining spinal alignment.
23 years old primigravida presents to you at fourteen weeks of gestation. She is concerned about normality of fetus. At what time you will advice her detailed fetal anomaly scan:
- A. 22-24 weeks.
- B. 14-16 weeks.
- C. 18-22 weeks.
- D. 10-14 weeks.
- E. 24-28 weeks.
Correct Answer: C
Rationale: A detailed fetal anomaly scan is typically performed between 18-22 weeks of gestation as this is the optimal time to visualize fetal anatomy clearly. Earlier scans (10-14 weeks) are for nuchal translucency and later scans may miss the window for detailed structural assessment.
The nurse assesses that the full-term newborn’s head has molding. Considering this finding,which information should the nurse expect to see on the mother’s labor and delivery documentation?
- A. Vaginal breech birth
- B. Planned cesarean birth,no labor
- C. Was in labor for 16 hours
- D. Precipitous delivery after a 30-minute labor
Correct Answer: C
Rationale: A 16-hour labor causes molding due to prolonged pressure of the fetal head against the cervix. Breech births cesarean sections or short labors produce minimal or no molding.