Nokea
While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?
- A. Dyspnea
- B. Tachypnea
- C. Cheyne-Stokes respirations
- D. Seesaw (paradoxic) respirations
Correct Answer: C
Rationale: Cheyne-Stokes respirations are characterized by alternating periods of deep, rapid breathing followed by periods of apnea. This cyclic pattern of respiration is often seen in critically ill patients and can be a sign of serious neurological or cardiac dysfunction. The nurse should document Cheyne-Stokes respirations when observing this specific breathing pattern in the child described in the scenario.
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A patient, age 46, is admitted for observation following an auto accident. He hit the steering wheel and has a chest contusion. Which of the following creates a pericardial friction rub?
- A. Inflamed cardiac tricuspid and mitral valves
- B. Decreased cardiac output c.Increased pulmonary pressures
- C. Rubbing of pericardial and epicardial layers
Correct Answer: C
Rationale: A pericardial friction rub is a harsh grating sound caused by the rubbing of the pericardial and epicardial layers of the heart. This rubbing sound can be heard with a stethoscope and is typically indicative of pericarditis, inflammation of the pericardium (the sac surrounding the heart). In the case of the patient with a chest contusion following an auto accident, the trauma could have led to pericardial inflammation and subsequent pericardial friction rub. The other choices do not directly result in the creation of a pericardial friction rub.
The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
- A. Reassure the parent that it is not necessary to stay home with the child.
- B. Explain that no medication will shorten the course of the illness.
- C. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
- D. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
Correct Answer: B
Rationale: The most appropriate nursing intervention in this scenario is to explain to the parent that no medication will shorten the course of chickenpox. Chickenpox is a viral illness caused by the varicella-zoster virus, and there is no specific treatment to shorten its duration. Antiviral medications like acyclovir are typically reserved for severe cases or for individuals with compromised immune systems. VCZ immune globulin (VariZIG) is used for post-exposure prophylaxis in susceptible individuals who have been exposed to chickenpox and are at high risk for severe disease.
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
- A. 2-5 mmHg
- B. 10-15 mmHg
- C. 5-10 mmHg
- D. 20-25 mmHg
Correct Answer: A
Rationale: The amount of suction typically required for routine suctioning for adults using a portable suction unit at home is 80-120 mmHg for an adult patient. However, for children or individuals with sensitive airways, the recommended amount of suction is lower, ranging from 2-5 mmHg. Since the question mentions that James is using the unit at home, it is safer to assume that a lower amount of suction (2-5 mmHg) would be appropriate for his needs.
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
- A. Wrap the neonate warmly and place her in an open crib
- B. Administer an oral glucose feeding of 10% dextrose in water
- C. Increase the temperature setting on the radiant warmer
- D. Obtain an order for IV fluid administration
Correct Answer: A
Rationale: The neonate is likely experiencing hypothermia with an axillary temperature below the normal range for a newborn. The best immediate action is to prevent further heat loss by wrapping the neonate warmly to maintain body temperature. Placing the neonate in an open crib will allow for better monitoring without the heat source of the radiant warmer. It is important to continue monitoring the neonate's temperature closely to ensure it returns to the normal range.