Nokea
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.
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Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
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.
Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.
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.
Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.