Exam 2 fall 23

 The nurse is caring for an infant with a myelomeningocele who is awaiting closure of the defect. Which assessment finding is of most concern?

• Bulging of the sac when the infant cries

• Fever of 101.4F

• Flaccidity bilateral lower extremities

• oozing of stool from the rectal sphincter

What would you hear on a patient with a pneumothorax?

• Wheezing on affected side

• Absent Breath sounds on the affected side

• Crackles on affected side

• Hypo-resonance on affected side

Which of the following is a normal finding for the client with a chest tube?

• New areas of subcutaneous emphysema

• Continuous bubbling in the water seal chamber

• Drainage from the chest tube increases each day

• The water level in the water seal chamber fluctuates with respirations.

Which is an example of secondary prevention?

• Physical therapy for a stroke client

• Immunization of children against measles

• Teaching about birth control

• Screening for hypertension

 The nurse is providing teaching and anticipatory guidance to the caregivers of a 6-year-old child recently diagnosed with DMD. Which will the nurse include?         Select all that apply.

• Tell me about your support system.

• Does obesity run in your family?

•  When the time comes, your healthcare provider will provide information about organ donation.

•  You will need to purchase large diapers for your child as he becomes incontinent.

•  What activities does your child enjoy?

The nurse is assessing the functioning of a chest tube drainage system in a client who has a traumatic pneumothorax. Which are the expected assessment findings? Select all that apply.

• Excessive bubbling in the water seal chamber

• Occlusive dressing in place over the chest tube insertion site

• Drainage system maintained below the client's chest

• 50 mL of drainage in the drainage collection chamber

• Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

The nurse is assessing a client with suspected cystic fibrosis​ (CF). Which clinical manifestation should the nurse recognize as a hallmark sign of the disease that would support this​ suspicion?

• An increased amount of chloride in the sweat

• A decreased amount of chloride in the sweat

• A decreased amount of chloride in the nasal secretions

• An increased amount of chloride in the nasal secretions

The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?

• The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.

• The client will be administered an injection of antidiuretic hormone, and urine output will be measured for 4 to 6 hours.

• The client will be NPO, and vital signs and weights will be obtained hourly until the end of the test

• An IV will be started with normal saline, and the client will be asked to try and hold their urine until a sonogram can be preformed

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply

• Restrict fluids

• Weigh client every 2 days

• Place seizure precautions in room

• assess level of consciousness

• Place patient on IV fluids per order

You are completing discharge teaching on a patient who has systemic lupus erythematosus. What will the nurse include? Select all that apply

• Report fever

• Encourage Vitamin D and Calcium

• Encourage outdoor activities

• Encourage Support groups

• Follow clients wishes about immunizations