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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.

Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.

Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.

Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).

Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.

A. Use a client-specific stethoscope. B. Wipe the medication cart with bleach after bringing it into the room. C. Measure the client's temperature with a disposable thermometer. D. Change gloves between different clients. E. Pad the client's side rails with clean linens.

Correct Answer is ["A","C","D"]

Explanation

A. Use a client-specific stethoscope.
Indicated: Using a client-specific stethoscope helps prevent the spread of MRSA between patients. Each client should have dedicated equipment to reduce cross-contamination.
B. Wipe the medication cart with bleach after bringing it into the room.
Not Indicated: While disinfection of surfaces is important, the cart should be cleaned according to hospital protocol, which may involve different cleaning agents. Bleach is not typically used for medication carts and might not be the standard protocol.
C. Measure the client's temperature with a disposable thermometer.
Indicated: Using a disposable thermometer or single-use covers for thermometers prevents the transmission of MRSA to other patients. This practice helps maintain infection control.
D. Change gloves between different clients.
Indicated: Gloves should be changed between patients to prevent the spread of MRSA. This is a standard infection control practice to avoid cross-contamination.
E. Pad the client's side rails with clean linens.
Not Indicated: While padding the side rails may be done for client comfort or safety, it does not specifically address the control of MRSA spread and is not a direct infection control measure for MRSA.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Exhibits Which 3 other interventions can the practical nurse (PN) initiate to limit the spread of methicillin-resistant Staphylococcus aureus (MRSA)?

Correct Answer is ["A","C","D"]

Explanation

The practical nurse (PN) is assigned to provide care for a client with rheumatoid arthritis who is preparing for discharge. While planning the client's care, the PN should identify which client goal as the most important?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. What client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? Select all that apply.

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Exhibits The practical nurse (PN) notifies the healthcare provider that the client continues to have signs of fluid volume deficit. The health care provider prescribes a continuous infusion of isotonic fluids. Which fluid(s) is/are classified as isotonic? Select all that apply.

The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the practical nurse (PN) identify as having the greatest impact on the development of this newborn complication?

Which intervention should the practical nurse (PN) reinforce for a client with pruritis?

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.