Nokea
Which of the following should the nurse do first for a toddler just admitted with croup?
- A. Monitor vital signs
- B. Assess respiratory status
- C. Ensure adequate fluid intake
- D. Place a tracheostomy set at the bedside
Correct Answer: B
Rationale: Assessing respiratory status is the priority for a toddler with croup, as airway obstruction is a primary concern. Vital signs, fluids, and tracheostomy preparation are secondary.
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The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
A client has been taking furosemide (Lasix) for 2 days. The nurse should assess the client for:
- A. An elevated blood urea nitrogen (BUN) level.
- B. An elevated potassium level.
- C. A decreased potassium level.
- D. An elevated sodium level.
Correct Answer: C
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, requiring assessment for decreased potassium levels.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
- A. Report this to the social worker
- B. Call Child Protective Services
- C. Wait until the father arrives
- D. Inform the physician that the mother has refused to have the procedure
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.
The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
- A. Anxiety
- B. Depression
- C. Suicidal ideation
- D. Ineffective coping
Correct Answer: C
Rationale: Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression.