Exhibits

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

Course breath sounds

Decreased level of consciousness

Seizure activity

Irritability

Bradycardia

Answer and Explanation

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

Course breath sounds - Respiratory Distress

Decreased level of consciousness - Cerebral Edema

Seizure activity - Cerebral Edema

Irritability - Both (Can be associated with both cerebral edema and respiratory distress)

Bradycardia - Cerebral Edema

Rationale:

Course breath sounds - Respiratory Distress

Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.

Decreased level of consciousness - Cerebral Edema

A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.

Seizure activity - Cerebral Edema

Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.

Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.

Bradycardia - Cerebral Edema

Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.

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Free Nursing Study Resources

Correct Answer is ["400"]

Explanation

To calculate the mL/hr rate for the infusion pump, we can use the following formula: mL/hr = (Total volume to be infused in mL) / (Time in hours)

In this case, the total volume to be infused is 200 mL, and the infusion time is 30 minutes, which is equal to 0.5 hours.

mL/hr = 200 mL / 0.5 hours mL/hr = 400 mL/hr

Therefore, the nurse should program the infusion pump to deliver 400 mL/hr.

A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

Correct Answer is C

Explanation

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["400"]

Explanation

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

Correct Answer is C

Explanation

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Exhibits here What should the nurse include in pre-discharge education for this child's parents? Select all that apply.

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

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?

Exhibits

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