GUIDE WITH VERIFIED SOLUTIONS
◉ Evisceration. Answer: Evisceration is the complete separation of a
wound with protrusion of the viscera, which usually occurs 7-10
days Post Operative.
◉ A client is in buck's skin traction, where should the PN assess for
infection. Answer: Insertion of a pin into bone places the client at
risk for infection of the bone and surrounding tissues. It is most
important for the PN to asses the area surrounding the skeletal pin
insertion for signs of inflammation.
◉ What should be monitored in a client with hydrocephalus?.
Answer: The effectiveness of the shunt is determined by monitoring
the daily head circumference, body temperature and intake and
output.
◉ Glomerulonephritis and hematuria. Answer: Presents with urine
color changes due to hematuria, proteinuria and renal dysfunction
that causes fluid retention edema and hypertension without or
without oliguria. The typical motivator for the parents to seek
medical help for a child is hematuria.
, ◉ What intervention should the PN use to help decrease the stress
of a pediatric client?. Answer: Common fears of toddlers include the
loss of parents and fear of strangers. Allowing the child to be held by
the primary caregiver is likely to help reduce the child's stress.
◉ Medication and photosensitivity. Answer: Medications that cause
photosensitivity increase sensitivity to sun light. The client should
be reminded to protect skin from sunlight.
◉ A persistent dry cough is a side effect of what drug(s)?. Answer: A
persistent dry cough is a side effect of the antihypertensive agent
quinapril, an angiotensin- Converting enzyme (ACE Inhibitor).
◉ What should the PN monitor in a client who is on antibiotics?.
Answer: The PN should monitor the clients WBC and the presence of
specific microorganisms in sputum and their sensitivity to the anti-
infective is determined by the sputum culture and sensitivity
analysis.
◉ How should the PN determine which client to see first?. Answer:
When deciding which client to assess first, the priority is the client
who is at highest risk for rapid deterioration due to cardiac
dysfunction and hypoxia.