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 B
Explanation
A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.
Correct Answer is C
Explanation
A. Body temperature is not directly relevant to the administration of zolpidem. Zolpidem is a sleep aid, so assessing body temperature is not necessary for this medication.
B. Bowel sounds are important for gastrointestinal assessments but are not related to the immediate considerations for zolpidem administration.
C. Assessing mental status is crucial before administering zolpidem because this medication can cause side effects like drowsiness, confusion, or impaired cognition. Ensuring the client’s mental status is appropriate helps prevent adverse effects.
D. Skin integrity is important for general health assessments but is not specifically relevant before administering a sleep aid like zolpidem.
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