Exhibits
Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies.
What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.
Subdural hemorrhage
Respiratory distress
Hyperthermia
Cerebral edema
Acute asphyxia
Hypertension
Correct Answer : B,D,E
A. Subdural hemorrhage
The head CT was negative for bleeding or edema, making a subdural hemorrhage unlikely.
B. Respiratory distress
Given the history of drowning and the current signs of respiratory acidosis (pH 7.31, PaCO2 51), the child is at high risk for respiratory complications, including distress.
C. Hyperthermia
Hyperthermia is not a typical immediate complication following drowning in cool water, and the current body temperature of the child is within the normal range.
D. Cerebral edema
Although the initial CT scan is negative for edema, secondary cerebral edema can develop hours after the incident, especially in cases of significant hypoxemia.
E. Acute asphyxia
The initial incident of drowning and the resultant hypoxemia (as indicated by abnormal blood gases) place the child at risk for complications related to acute asphyxia.
F. Hypertension
The child's blood pressure is currently within normal limits, and hypertension is not a common immediate complication following drowning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Observing for signs of pain or discomfort during the treatment is not a direct method for evaluating ondansetron’s effectiveness. Ondansetron is used to prevent nausea and vomiting, not to manage pain.
B. While assessing vital signs is important for overall monitoring, it does not specifically measure the effectiveness of ondansetron for preventing nausea and vomiting.
C. Monitoring for nausea or vomiting following the treatment is the most direct way to evaluate the effectiveness of ondansetron. The primary goal of ondansetron is to prevent or reduce these symptoms associated with chemotherapy.
D. Evaluating if the client feels calm and relaxed is not a measure of ondansetron’s effectiveness. The focus should be on the medication’s ability to prevent nausea and vomiting rather than the client's emotional state before treatment.
Correct Answer is B
Explanation
A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.
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