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The RNteachesaptnewlydx'd with DM1aboutstoringHumulinN insulin.Which statement
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indicates to the RN that the pt understood the d/c teaching?
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a) "Iwouldkeeptheinsulin inthecabinetduringthedayonly."
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b) "IknowIhave tokeepmyinsulin intherefrigeratoratalltimes."
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c) "Ican storetheopeninsulinbottlesinthe kitchen cabinetfor1month."
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d) "Thebestplaceformy insulin isonthe windowsill, but inthecupboard is justas good." -
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CORRECT ANSWERS c) "I can store the open insulin bottles in the kitchen cabinet for 1 month."
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Rationale:
Aninsulinvialincurrentusecanbekeptatroomtemperaturefor1monthwithout
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significantlossofactivity.Directsunlightandheatmustbeavoided.Therefore,options1,2, and 4d d d d d d d d d d d d d d d d
are incorrect.
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TheRNiscaringforaptscheduledforatranssphenoidalhypophysectomy.Thepre-op teaching
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instructions would include which statement?
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a) "Yourhair willneed tobe shaved." d d d d d d
b) "Youwillreceivespinalanesthesia." d d d d
c) "Youwillneedtoambulateaftersurgery." d d d d d d
d) "Brushing your teethneeds to be avoided forat least 2 weeks post-op." - CORRECT d d d d d d d d d d d d d d
ANSWERS d)"Brushingyourteethneedstobeavoidedforatleast2weekspost-op."
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Rationale:
Atranssphenoidalhypophysectomyisasurgicalapproachthatusesthenasalsinusesand
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noseforaccesstothepituitarygland.Based onthe location ofthesurgicalprocedure, spinal
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anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is
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important,specific to this procedure is avoiding brushing theteeth to prevent disruption of the
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surgical site.
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During a routine prenatal visit, a pt complains of easily bleeding gums when brushing. The RN
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does an assessment & teaches the pt about proper nutrition to minimize this problem. Which pt
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statement indicates an understanding?
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a) "I will drink8oz ofwater with each meal."
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b) "Iwilleat 3servingsofcracked wheatbread each day."
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c) "Iwilleat2saltinecrackers beforeIgetupeachmorning."
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d) "Iwilleatfreshfruits&veggiesfor snacks&for dessert eachday." - CORRECT ANSWERS
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d)"I will eatfreshfruits&veggies for snacks &for dessert eachday."
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Rationale:
Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking
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water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums.
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Eating saltine crackers can also abrade the tender gums.
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A6 yochildwasjustdx'dwithHodgkin'sdisease&chemoisplannedtobeginimmediately. The
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parent asks the RN why XDR was not ordered as part of tx. The RN should make which response?
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a) "It'svery costly &chemo works justas well."
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b) "I'm not sure. I'lldiscuss it with theHCP." d d d d d d d d
c) "Sometimesagehasto dowiththedecisionfor XDR." d d d d d d d d d
d) "TheHCPwouldprefer thatyoudiscussthetxoptionswiththeoncologist." - CORRECT
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ANSWERS c) "Sometimes age has to do with the decision for XDR."
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Rationale:
Radiation therapy is usually delayed, whenever possible, until a child is 8 years old to prevent
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retardationofbonegrowthandsofttissuedevelopment.Options1,2,and4are inappropriate
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responses to the parent and place the parent's question on hold.
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The RNisdoinganinitialassessmentonanewborn infant.When assessingthe infant'shead, the RN
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notes that the ears are low-set. Which RN action is most appropriate?
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a) Documentthe findings. d d
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b) Arrangeforahearingtest. d d d d
c) Notify the pediatrician. d d
d) Coverthe earswith gauzepads. - CORRECT ANSWERS
d d d d d d d d c) Notifythe pediatrician.
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Rationale:
Low or oddly placed ears are associated with various congenital defects and need to be reported
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immediately.Althoughthefindingsneedtobedocumented,themostappropriate actionwouldbe
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tonotifythepediatrician.Options2and4 areinaccurateandinappropriate nursing actions.
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What PO2 value indicates respiratory failure in adults? - CORRECT ANSWERS
d d d d d d d d d d PO2<60 d d
mmHg
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Whatbloodvalueindicateshypercapnia?- CORRECTANSWERS
d d d d d d d PCO2 > 45 mmHg d d d
WhatconditionoccurswhenthePO2is< 60mmHg(acutehypoxemia),theCO2 tension rises > 50
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mmHg (acute hypercarbia, hypercapnia) & the pH drops < 7.35, or both? -
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CORRECTANSWERS Acuterespiratoryfailure d d d
What are the S/S of respiratory failure in adults? - CORRECT ANSWERS
d d d d d d d d d d d Dyspnea,SOB d
Tachypnea
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Intercostal&sternalretractions d d d
Cyanosis
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Tachycardia
Coughthatproducessputum d d d
Fatigue
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Fever
Crackles,wheezes d
Chestpain(especiallywhentryingtodeepbreathe) Hypotension
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Confusion
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Agitation,restlessness d
What are the common causes of respiratory failure in peds? - CORRECT ANSWERS
d d d d d d d d d d d d CHD
RDS
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Infection,sepsis d
NM diseases
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Trauma, burns
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Aspiration
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FVO & dehydration Anesthesiad d d
&narcoticOD
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Structuralanomaliesresultinginairwayobstruction d d d d d
WhatpercentageofO2shouldachildinsevererespiratorydistressreceive? - CORRECT
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ANSWERS 100% O2
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What is shock? - CORRECT ANSWERS Widespread,seriousreductionoftissueperfusion,
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which leads to generalized impairment of cellular function.
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Whatisthe mostcommon causeofshock? - CORRECT ANSWERS
d d d d d d d d d d Hypovolemia
What causes septic shock? - CORRECT ANSWERS Release of endotoxins from bacteria,
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which act on the nerves in peripheral vascular spaces, causing vascular pooling, reduced
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venous return, decreased CO & results in poor systemic perfusion.
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What is the goal of tx for hypovolemic shock? - CORRECT ANSWERS
d d d d d d d d d d d Quickrestorationof d d
CO & tissue perfusion.
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It's important to differentiate between hypovolemic & cardiogenic shock. How might the RN
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determine the existence of cardiogenic shock? - CORRECT ANSWERS H/o MI with LV failure or
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possible cardiomyopathy, with S/S of pulmonary edema.
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Ifaptisincardiogenicshock,whatmightresultfromadministrationofvolume-expanding fluids,
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and what intervention can the RN expect to perform in the event of such an
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