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While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
- A. Notify the physician to obtain further orders.
- B. Mark the dressing and continue to monitor.
- C. Check the dressing for the presence of glucose with a Dextrostik.
- D. No action is necessary because some drainage is expected.
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
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A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
A client had a thoracotomy 3 hours ago. For the past 2 hours there has been 100 cc per hour of bloody chest drainage. Which of the following actions should the nurse take FIRST?
- A. Increase the IV fluid rate.
- B. Administer oxygen at 5 L/min per oxygen mask.
- C. Elevate the head of the bed.
- D. Advise the physician of the amount of drainage.
Correct Answer: D
Rationale: Excessive chest drainage (100 cc/hour) suggests hemorrhage, requiring immediate physician notification. Options A, B, and C are secondary interventions.
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- A. Vegetables
- B. Cereal
- C. Fruit
- D. Meats
Correct Answer: B
Rationale: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema