Exhibits

The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).

Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.

Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.

Cerebral edema

Acute asphyxia

Hypertension

Respiratory distress

Hyperthermia

Subdural hemorrhage

Answer and Explanation

Correct Answer : A,B,D,F

A)   Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B)   Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C)   Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D)   Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E)   Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F)   Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.

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Correct Answer is C

Explanation

Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.

While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.

Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.

A. Observe for swelling at the fracture site. B. Analyze the cardiac rhythm in another lead. C. Obtain a 12-lead electrocardiogram. D. Begin chest compressions at 100/minute.

Correct Answer is D

Explanation

The correct answer is choice D: Begin chest compressions at 100/minute.

Choice A rationale:

Observing for swelling at the fracture site is not immediately relevant in this emergency situation. The priority is to address the lack of pulse and respiration.

Choice B rationale:

Analyzing the cardiac rhythm in another lead is unnecessary when the patient has no pulse and is not breathing. Immediate life-saving measures are required.

Choice C rationale:

Obtaining a 12-lead electrocardiogram is not the priority in this scenario. The patient needs immediate resuscitation efforts.

Choice D rationale:

Beginning chest compressions at 100/minute is the correct intervention. The absence of a carotid pulse and spontaneous respirations indicates cardiac arrest, and chest compressions are essential to maintain circulation and oxygenation until further help arrives.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

Correct Answer is C

Explanation

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?