Pediatrics
After an orthopedic surgery, a 15 year old reports a pain rating of 5 on a 0 to 10 scale. The adolescent is given 5 mg or oxycodone as ordered every 3 hours PRN. Two hours after having been given this medication, the adolescent reports pain 10 out of 10. What action should the nurse take? ---------------------------------------------------------------------------------- A. Administer another dose of oxycodone within thirty minutes.
B. Report that the adolescent has an apparent idiosyncrasy to oxycodone.
C. Tell the adolescent that additional medication cannot be given for 1 more hour.
D. Request that the practitioner evaluate the adolescent's need for additional medication.
d. Request that the practitioner evaluate the adolescent's need for additional medication. Rationale: The nurse made the assessment that the pain medication was ineffective at relieving the adolescent's pain for the duration ordered. This information should be communicated to the practitioner for evaluation.
1. A client receiving a continuous infusion of heparin IV starts to hemorrhage from an arterial access site. What medication should the nurse anticipate administering to prevent further heparin-induced hemorrhaging?-----------------------------------------------------------------
A. Vitamin K
B. Protamine Sulfate
C. Warfarin Sodium (Coumadin)
D. Prothrombin
B. Protamine Sulfate-Rationale: Protamine sulfate is the antagonist for heparin and is given for episodes of acute hemorrhage.
1. Using Nagele’s rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client’s estimated date of delivery would be which of the following?----------------------------
A. January 13
b. January 17
c. February 13
d. February 17
d. February 17: Rationale- When using Nagele’s rule to determine the estimated date of delivery, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days.
1. The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?-----------------------------------------------------------------
1. Hypertension, changes in level of consciousness, hallucinations.
2. Hypotension, ataxia, hunger
3. Stupor, agitation, muscular rigidity
4. Hypotension, coarse hand tremors, agitation
1. Hypertension, changes in level of consciousness, hallucinations. Rationale: Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, fever and delusions.
1. A nurse is creating a plan of care for a patient scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?------------------------------------------------------
a. Have the client void immediately before surgery.
b. Avoid oral hygiene and rinsing with mouth wash.
c. Report immediately any slight increase in blood pressure or pulse.
d. Verify that the client has not eaten for the last 24 hours.
Answer. A. The nurse should have the patient void so that the bladder will be empty. Oral hygiene is allowed before surgery as long as no water is swallowed. A slight increase of blood pressure and pulse is common before surgery due to anxiety and should not be reported. The patient should have had fluids and food restricted for 8 hours before surgery not 24.
2. The nurse plans specific care for infants, based on the knowledge that infants are at greater risk for a fluid volume deficit and hyperosmolar imbalance than adults because: ----------------------------------------------------------------------------------
A. Their metabolic processes are slower.
b. They have a slower glomerular filtration rate.
c. Their body fluid loss is proportionately greater per kilogram of weight.
d. They have not yet developed a generalized response to insensible fluid loss.
c. Their body fluid loss is proportionately greater per kilogram of weight. Rationale: Infants are not protected from water loss because they ingest and exrete a relatively greater volume than adults; therefore the proportion of total body water is higher.
2. The nurse gives a client NPH insulin 15 units SQ before breakfast (7:30am). At what time should the nurse be particularly alert for signs or symptoms of a potential hypoglycemic reaction?----------------------- A. 1:30-3:30pm
B. 8:30-11:30 am
C. 7:30-9:30pm
D. 12:00 midnight
A. 1:30-3:30pm- Rationale: NPH, an intermediate acting insulin, peaks within 4-12 hours after SQ injection.
2. During a 2-hour childbirth preparation class focusing on the labor and delivery process for primigravid clients, the nurse describes the first maneuver that the fetus goes through during the labor process when the head is presenting part as which of the following?----------------
A. Engagement
B. Flexion
c. Descent
D. Internal Rotation
c. Descent: Rationale- If the head is the presenting part, the normal maneuvers during labor and delivery are descent, flexion, internal rotation, extension, external rotation, and expulsion. These maneuvers are called the cardinal movements.
2. The nurse is caring for a client with a phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse understands that this form of behavior modification can best be described as:-----------------------------------
1. Systematic desensitization
2. Self-control Therapy
3. Milieu Therapy
4. Aversion Therapy
1. Systematic desensitization. Rationale: Gradual exposure is increased until the anxiety about or fear of the object or situation has ceased.
2. A nurse is assessing a postoperative client after surgery for signs of complications. The nurse is looking for Homan’s sign. The nurse determines the sign is positive when which of the following is noted?---------------------------------------
a. Crackles on auscultation of the lungs
b. Pain with dorsiflexion of the foot
c. Incisional pain
d. Absent bowel sounds
B. To find Homan’s sign the nurse dorsiflexes the patient’s foot to see if the client feels pain in their calf. If pain is present then the sign is positive, which is an indication of thrombophlebitis. The other answers are incorrect as none of them are ways to find Homan’s sign.
3. A peripheral central venous catheter has just been inserted in the arm of a 7-year-old child on the pediatric unit. A peripheral IV line is still in place. An antibiotic is to be administered immediately. Which intrevenous access line should the nurse use for the antibiotic infusion and why? ----------------------------------------------------------------------------------
a. Central venous catheter, because this will help determine its patency.
b. Peripheral line, because the central venous catheter is reserved for fluids.
c. Central venous catheter, because the antibiotic must be given systemically as quickly as possible.
d. Peripheral line, because the central venous catheter placement has not been confirmed by radiograph.
d. Peripheral line, because the central venous catheter placement has not been confirmed by radiograph. Rationale: The peripheral line must be used until the placement of the central venous line is confirmed by radiography or fluoroscopy; this prevents fluid from entering the lung or interstitial space if the catheter is misplaced.
3. In addition to nitrate therapy, a client is receiving nifedipine (Procardia) 10 mg PO q6h. The nurse should plan to observe for which common side effect of this treatment regimen?---------------------------
A. hyperkalemia
B. hypokalemia
C. hypotension
D. seizures
C. Hypotension. Rationale: Nifedipine (Procardia) reduces peripheral vascular resistance and nitrates produce vasodilation, so concurrent use of both can cause hypotension with the initial administration of the drugs.
3. For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?-----------------------------------
a. Decreased deep tendon reflexes
b. Cool skin temperature
c. Rapid pulse rate
d. Tingling in the toes
a. Decreased deep tendon reflexes: Rationale- Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, impaired respirations, and lethargy progressing to coma as the toxicity increases
3. The client is unwilling to go out of the house for fear of “doing something crazy in public.” Because of this fear the client remains homebound except when accompanied outside by the spouse. Based on this data, the nurse determines that the client is experiencing:--------------------------------------
1. Social Phobia
2. Agoraphobia
3. Claustrophobia
4. Hypochondriasis
2. Agoraphobia. Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment.
3. An ER nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of the following signs would indicate the presence of a pneumothorax?------------------------------------------------
a. The presence of a barrel chest
b. A low respiratory rate
c. Diminished breath sounds on one side of the chest
d. A sucking sound at the site of the injury
Answer- C. Diminished breath sounds on one side of the chest are a classic sign of a pneumothorax. Another finding would be tachypnea rather than a low respiratory rate. A sucking sound at the site of an injury would only be present in an open chest injury. A barrel chest is indicative of a chronic respiratory problem such as COPD.
4. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse notes that the respiratory rate is less than 24 breaths/minute. No other changes are observed, and because the infant is apparently well, there is no report or documentation of the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. Legal responsibilty in this instance should take into consideration that: ----------------------------------------------------------------------------------
a. Most infants' respirations are slow when they are uncomfortable.
b. The respirations of young infants are irregular so a drop in rate is unimportant.
c. Vital signs that are outside the expected parameters are significant and should be documented.
d. The respiratory tract of young infants is underdeveloped and their respiratory rate is not significant.
c. Vital signs that are outside the expected parameters are significant and should be documented. Rationale: A respiratory rate below 30 breaths/minute in the young infant is not within the expected range of 30 - 60 breaths/minute; a drop below 30 breaths/minute is a significant change and should be documented.
4. A female client who has started taking long-term corticosteroid therapy tells the nurse that she is careful to take her daily dose at bedtime with a snack of crackers and milk. What is the best response by the nurse?------------------------------------------------------------------
A. Advise the client to take the medication in the morning, rather than at bedtime.
B. Teach the client that dairy products should not be taken with her medication.
C. Tell the client that absorption is improved when taken on an empty stomach.
D. Affirm that the client has a safe and effective routine for taking the medication.
Answer A take in morning - Rationale: Daily doses of long-term corticosteroid therapy should be administered in the morning, to coincide with the body's normal secretion of cortisol.
4. Assessment reveals that the fetus of a primigravid client is at + 1 station. The nurse interprets this finding as indication that the fetal presenting part is positioned at which of the following?----------------------
a. 1 cm above the ischial spines
b. 1 cm below the ischial spines
c. 1 cm above the ischial tuberosities
d. 1 cm below the sacral promontory
B. 1 cm below the ischial spines: Rationale- the ischial spines are used as landmarks to determine the descent of the fetal presenting part. The station +1 means that the presenting part is 1cm below the level of the ischial spines. The station -1 means that the presenting part is 1 cm above the level of the ischial spine
4. A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car accident, when a family of three was killed. The nurse suspects that the client may be experiencing:-------------------------------------------------------
1. Psychosis
2. Conversion Disorder
3. Dissociative Disorder
4. Repression
2. Conversion Disorder. Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathological mechanism. A conversion disorder is thought to be an expression of a physiological need or conflict. In this situation the client witnessed an event that was so psychologically painful that the client became blind.
4. The nurse suspects that a patient has developed a pulmonary embolism. Which symptoms would the nurse expect to see in the patient?-----------------------------------------------------------------------
a. Sudden chills and fever
b. Hot, flushed feeling
c. Sudden chest pain
d. Tingling around the mouth
C. The most comment sign of a pulmonary embolism is sudden chest pain. The other options are not signs of a pulmonary embolism.
5. A 4-year-old girl is brought to the emergency department after falling on the handlebars of her tricycle. She is guarding her abdomen, crying, and not allowing anyone to touch her. Which action best enables the nurse to initiate the assessment process? ----------------------------------------------------------------------------------
a. Medicate the child for pain before proceeding.
b. Allow the child to guide the examiner's hand to the area that hurts.
c. Have the parent restrain the child while the abdomen is auscultated.
d. Suggest the practitioner order a CAT scan, because a child this age is unable to cooperate.
b. Allow the child to guide the examiner's hand to the area that hurts. Rationale: The child will move her hand to the abdomen; the nurse can then engage the child's cooperation and do a general assessment.
5. Which assessment finding could indicate to the nurse that a client is experiencing an adverse effect of the GI stimulant metoclopramide (Reglan)?-----------------------------------------------------------------------
A. Complains of dizziness when first getting up.
B. Describes an unpleasant metallic taste in the mouth.
C. Refuses to drive after 6pm because of an inability to see well at night.
D. Demonstrates Parkinson-like symptoms, such as cogwheel rigidity.
D. Demonstrates Parkinson-like symptoms, such as cogwheel rigidity.- Rationale: Reglan blocks dopamine receptors in the brain which can cause the extrapyramidal symptoms associated with Parkinson's disease.
5. A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, “Can I continue to breast-feed my baby?” Which of the following responses by the nurse would be most appropriate?-----------------------------------------------------
a. You can continue to breast-feed as long as you want to do so?”
b.“Alternate you breast-feeding with formula feeding to help you rest.”
c. “You’ll need to discontinue breast-feeding until the antibiotic therapy is stopped.”
d. You’ll need to modify your technique by manually pumping your breasts.”
a. “You can continue to breast-feed as long as you want to do so?”: Rationale- The client can continue to breast-feed as often as she desires. Continuation of breastfeeding is limited only by the client’s discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk.
5. The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse assesses the results of what laboratory study to monitor for adverse effects from this medication?------------------------------------------------------------------------
1. Platelet Count
2. Blood Glucose
3 White Blood Cell Count
4. Liver Function Studies
3 White Blood Cell Count. Rationale: The client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count.
5. A patient with diabetes has had a left below the knee amputation. The nurse would assess specifically for which of the following signs and symptoms based upon the patient’s history?--------------------------------------------
a. Hemorrhage
b. Edema of the stump
c. Slight redness of the incision
d. Separation of the wound edges
D. Patients with Diabetes are more likely to develop a wound infection and have delayed wound healing. Edema and hemorrhage are both common complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.