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Which of the following findings should the nurse expect?
- A. Cyanosis
- B. Weight loss
- C. Bounding peripheral pulses
- D. Dyspnea
- E. Tachycardia
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Cyanosis indicates poor oxygenation, dyspnea signifies difficulty in breathing, and tachycardia suggests an increased heart rate to compensate for decreased oxygen levels. Weight loss and bounding peripheral pulses are not typical findings in a patient with impaired oxygenation. In summary, the nurse should expect cyanosis, dyspnea, and tachycardia as key findings in a patient with compromised oxygenation.
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Which of the following oils should the nurse recommend?
- A. Lavender
- B. Eucalyptus
- C. Jasmine
- D. Tea tree
Correct Answer: A
Rationale: The nurse should recommend lavender oil because it is known for its calming and relaxing properties, which can help reduce stress and promote better sleep. Lavender oil has therapeutic benefits for anxiety and insomnia, making it a suitable choice. Eucalyptus is more commonly used for respiratory issues, jasmine for relaxation, and tea tree for skin conditions. Lavender stands out as the most appropriate option based on the context of the question.
Which of the following actions should the nurse take?
- A. Administer chlorothiazide.
- B. Hold the child down.
- C. Place the child in a prone position.
- D. Time the episode.
Correct Answer: D
Rationale: The correct action is D: Time the episode. By timing the episode, the nurse can gather important data to assess the duration and severity of the situation, aiding in diagnosis and treatment planning. Administering chlorothiazide (A) without assessing the situation first could be harmful. Holding the child down (B) may escalate the situation and cause distress. Placing the child in a prone position (C) could worsen their condition. Timing the episode (D) is essential for accurate evaluation.
Which of the following findings should the nurse report to the provider?
- A. Drainage from the chest tube of 22 mL in the last hour
- B. Urine output of 15 mL in the last 2 hr
- C. Skin temperature 36° C (96.8° F)
- D. Pedal and posterior tibial pulses of 2+
Correct Answer: B
Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.
The nurse should immediately report which of the following findings to the provider?
- A. Rhinorrhea
- B. Pharyngitis
- C. Coughing
- D. Tachypnea
Correct Answer: D
Rationale: The correct answer is D: Tachypnea. Tachypnea, which is rapid breathing, can indicate respiratory distress or an underlying serious condition that requires immediate attention. Reporting this finding promptly is crucial to ensure timely intervention. Rhinorrhea, pharyngitis, and coughing are common symptoms that may not require urgent attention as they can be managed symptomatically. In summary, tachypnea is the most concerning symptom that warrants immediate reporting, while the other choices are less urgent and can be addressed in due course.
Which of the following statements should the nurse include?
- A. Your child will have chest x-rays periodically to monitor for disease reactivation.
- B. Your child might need to have their tonsils and adenoids removed.
- C. Your child should take pancreatic enzymes with meals and snacks.
- D. Your child will take isoniazid for 9 months.
Correct Answer: C
Rationale: The correct answer is C: Your child should take pancreatic enzymes with meals and snacks. This is the correct statement to include because it pertains to the management of cystic fibrosis, a condition that affects the pancreas' ability to produce digestive enzymes. Pancreatic enzymes help in digesting food properly, ensuring proper nutrient absorption.
Choice A is incorrect as chest x-rays are not typically used for monitoring cystic fibrosis. Choice B is incorrect as tonsil and adenoid removal is not a standard treatment for cystic fibrosis. Choice D is incorrect as isoniazid is a medication used to treat tuberculosis, not cystic fibrosis.