Friday, 28 February 2020

Question Of The Day, Medication and I.V. Administration
Q. The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 ml/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:

A. Discontinue the infusion.
B. Apply a warm soak to the site.
C. Stop the flow of solution temporarily.
D. Irrigate the needle with normal saline.

Correct Answer: A

Reason: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the I.V. line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the I.V. line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated I.V. sites should not be irrigated; doing so will only cause more swelling and pain.

Thursday, 27 February 2020

Question Of The Day, Basic Physical Care
Q. Communicating with parents and children about health care has become increasingly significant because:

A. Consumers of health care cannot keep up with rapid advances in science.
B. The influence of the media and specialization have increased the complexity of managing health.
C. Nurse educators have recognized the value of communication.
D. Clients are more demanding that their rights be respected.

Correct Answer: B

Reason: Today's health care network includes many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded media coverage of health care issues, parents are more aware of health care issues but cannot understand all the ramifications of possible health care decisions. Because of this expanded media coverage, health care consumers are more aware of advances in the science of health care. Nurses have always recognized the value of communication and that all nurses are teachers. Clients are more aware of their rights through media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well and communicating with parents and children should not be impacted by a client's knowledge or demand for those rights.

Wednesday, 26 February 2020

Question Of The Day, Genitourinary Disorders
Q. Which of the following laboratory findings is present in nephrotic syndrome?

A. Decreased total serum protein.
B. Hypercalcemia.
C. Hyperglycemia.
D. Decreased hematocrit.

Correct Answer: A

Reason: A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a finding related to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome.

Tuesday, 25 February 2020

Q. A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to:

A. Call for emergency assistance.
B. Attempt reinsertion of tracheostomy tube.
C. Position the client in semi-Fowler's position with the neck hyperextended.
D. Insert the obturator into the stoma to reestablish the airway.

Correct Answer: B

Reason: The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.

Monday, 24 February 2020

Q. A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

A. gather assessment data and notify the physician of the change in the client's status.
B. ask the physician to order an antipsychotic medication for the client.
C. consult with the social worker about the possibility of discharging the client from the facility.
D. tell the client that she'll punish him if he doesn't behave.

Correct Answer: A

Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

Thursday, 20 February 2020

Question Of The Day, The Neonate
Q. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

A. Rewarm the neonate gradually.
B. Rewarm the neonate rapidly.
C. Observe the neonate hourly.
D. Notify the physician when the neonate's temperature is normal.

Correct Answer: A

Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

Wednesday, 19 February 2020

Q. A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision?

A. Inserting an indwelling urinary catheter
B. Fundal massage
C. Administration of oxytocics
D. Pad count

Correct Answer: D

Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.

Tuesday, 18 February 2020

Question Of The Day, Antepartum Period
Q. A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

A. 7 weeks' gestation
B. 11 weeks' gestation
C. 17 weeks' gestation
D. 21 weeks' gestation

Correct Answer: B

Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.




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