Timothy, 10, frequently falls and has a waddling gait. His creatine kinase is 4,000 U/L (normal is 22-198 U/L). Echocardiogram reveals early signs of cardiomyopathy. What is the most urgent nursing priority?

Start a cardiac rehabilitation program.

Scoliosis screening

Administer pain management protocols

Respiratory assessment

Answer and Explanation

The Correct Answer is D

A.   While cardiac rehabilitation may be necessary for Timothy in the future due to his cardiomyopathy, his current symptoms and elevated creatine kinase levels warrant immediate attention to other potential complications.

B.   While scoliosis screening may be necessary given Timothy's symptoms, it is not the most urgent priority.
C.   Pain management may be necessary for Timothy, but his respiratory status should be assessed first to ensure adequate oxygenation.
D.   Given Timothy's symptoms and potential complications such as respiratory muscle weakness associated with his elevated creatine kinase levels, a respiratory assessment is the most urgent priority to ensure proper oxygenation and ventilation

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Correct Answer is B

Explanation

A. Mannitol is an osmotic diuretic used to reduce intracranial pressure. While maintaining an appropriate infusion rate helps prevent fluid overload, it's not the primary reason for the slow infusion rate.
B. Mannitol can crystallize at lower temperatures or higher concentrations, leading to occlusion of the IV line. Maintaining a slow infusion rate reduces the risk of crystallization.
C. Mannitol itself does not typically cause hyperglycemia. Its primary concern regarding infusion is related to crystallization rather than glucose metabolism.
D. Mannitol's impact on electrolyte balance is more related to its osmotic diuretic effect rather than the infusion rate.

A. Discuss the need for topical antibiotics. B. Prepare Sarah for a skin biopsy. C. Advise on the application of tretinoin. D. Teach her to use a corticosteroid cream.

Correct Answer is D

Explanation

A. There's no indication of a bacterial infection, so antibiotics are not warranted.

B. A biopsy may be considered if the diagnosis is uncertain, but it's not the first-line action.
C. Tretinoin is typically used for conditions like acne or photoaging, not for eczematous lesions.
D. Corticosteroid creams are commonly used to reduce inflammation and itching associated with eczema, making this the most appropriate action.

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Timothy, 10, frequently falls and has a waddling gait. His creatine kinase is 4,000 U/L (normal is 22-198 U/L). Echocardiogram reveals early signs of cardiomyopathy. What is the most urgent nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Lisa, a 29-year-old woman, is diagnosed with a subdural hematoma and is on an IV drip of mannitol at 50 mL/hr. Why is it crucial to maintain this slow infusion rate?

Correct Answer is B

Explanation

Sarah, a 30-year-old with a family history of eczema, presents with a scaly, erythematous plaque on her right cheek. Blood tests reveal normal inflammatory markers. What should the nurse do?

Correct Answer is D

Explanation

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