Evaluation EAQ
A nurse is planning to administer albuterol (Proventil) to a 4-year-old child. The nurse should evaluate the effectiveness of this medication by: Correct1 Auscultating breath sounds 2 Collecting a sputum sample 3 Conducting a brief neurological examination 4 Palpating chest excursion to gauge promotion of intercostal contractility
1 Auscultating breath sounds Albuterol is an adrenergic drug that stimulates β-receptors, leading to relaxation of the smooth muscles of the airway. The lungs should be auscultated to evaluate the effectiveness of this medication. Albuterol does not affect intercostal contractility; chest excursion is not the appropriate assessment. Albuterol does not affect the consistency of pulmonary secretions. Albuterol will not cause central nervous system stimulation.
A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? Correct1 Hemorrhage 2 Gastroparesis 3 Pulmonary embolism 4 Tension pneumothorax
1 Hemorrhage In the impaired liver, blood-clotting mechanisms are disrupted and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.
A neonate born at 36 weeks' gestation, weighing 2043 g (4 lb 8 oz), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/hr. Why is it important for the nurse to check the neonate's voidings for specific gravity? Correct1 Infants under open radiant warmers are at risk for dehydration. 2 This infusion rate is inadequate to meet a preterm infant's fluid needs. 3 Infants are unable to produce adequate amounts of urine at this gestational age. 4 Renal dysfunction is the complication that most frequently affects preterm infants.
1 Infants under open radiant warmers are at risk for dehydration. Open radiant warmers cause excessive fluid loss without electrolyte loss. This infusion rate, based on a rate of 100 mL/kg/day for maintenance fluid and an additional 88 mL/kg/day for fluid loss caused by the radiant warmer, is appropriate for an infant of this size. An infant at 36 weeks' gestation is able to produce sufficient quantities of urine but is unable to concentrate urine effectively. Respiratory distress syndrome is the most frequent complication in a preterm infant.
Sitz baths are ordered for a client with an episiotomy during the postpartum period. A nurse encourages her to take the sitz baths because they aid the healing process by: Correct1 Promoting vasodilation 2 Cleansing perineal tissue 3 Softening the incision site 4 Tightening the rectal sphincter
1 Promoting vasodilation Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.
The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating? Correct1 Taking-in 2 Letting-go 3 Taking-hold 4 Bonding failure
1 Taking-in During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.
A client has a diagnosis of partial-thickness burns. The nurse recalls that the client's burn is different than full-thickness burns in that partial-thickness burns: 1 Require grafting before they can heal Correct2 Are often painful, reddened, and have blisters 3 Cause destruction of both the epidermis and dermis 4 Often take months of extensive treatment before healing
2 Are often painful, reddened, and have blisters Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the superficial layers of skin, unless they become infected. Recovery from partial-thickness burns with no infection occurs in two to three weeks.
A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy that is not relieved with analgesics. What does the nurse conclude is the cause of the client's pain? 1 A normal response after delivery 2 Low tolerance of pain Correct3 Hematoma in the perineal area 4 Infection at the episiotomy site
3 Hematoma in the perineal area Pain becomes excruciating with hematoma development at the episiotomy site because of pressure on surrounding nerve endings. This pain is not relieved by the application of ice because ice only reduces edema formation around the incision. There are no data to indicate the presence of hemorrhoids. There are no data to indicate that the client has a low tolerance for pain. It is too early to assume that an infection has developed; pyrexia and local signs of infection would support this conclusion.
A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: 1 Oxidization of fatty acids 2 Shivering when chilled Correct3 Metabolism of brown fat 4 Increased muscular activity
3 Metabolism of brown fat Metabolism of brown fat releases energy and increases heat production in the newborn. Fatty acids are byproducts of the breakdown of brown fat. Shivering is the mechanism of heat production for an adult, not for a newborn. Increased muscular activity will not be successful unless there is an abundance of brown fat.
A nurse identifies that the client understands information about vitamin K when the client states, "Vitamin K is: 1 Found in a variety of foods, so there is no danger of deficiency." 2 Easily absorbed without assistance, so everything eaten is absorbed." 3 Rarely found in dietary foods, so a natural deficiency can easily occur." Correct4 Produced in sufficient amounts by intestinal bacteria, so metabolic needs are met."
4 Produced in sufficient amounts by intestinal bacteria, so metabolic needs are met." Vitamin K is synthesized by intestinal bacteria but also is found in large quantities in green leafy vegetables. Vitamin K is found only in specific foods, not a wide variety. Vitamin K is not easily absorbed; it is fat-soluble and requires bile salts for its absorption. It is synthesized by intestinal bacteria, so a natural deficiency does not occur.
A nurse at the well-child clinic determines a 1-year-old infant's length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant's current length be? Record your answer using a whole number. __________ inches
This infant is 2 inches shorter than expected. At 1 year of age an infant should have increased the birth length by 50%; 50% of 20 inches is 10 inches; 10 inches added to the birth length of 20 inches equals 30 inches.