Nursing Education Capstone (C947)

Correct Answer

B. Loosen the child's clothing, and call for help.

Explanation

During a seizure, safety and airway maintenance are priorities. The best action is to ease the child to the ground, protect them from injury by loosening clothing, especially around the neck, and move any dangerous objects away. Calling for help ensures timely emergency care if needed. Medications should not be administered orally during a seizure due to aspiration risk, and inserting anything in the mouth is dangerous.

Why other options are wrong

A. Administer the child's rescue dose of oral diazepam (Valium).

Oral medications should never be given during an active seizure because of the risk of aspiration and choking. If the child has a prescribed rescue medication, such as rectal diazepam or intranasal midazolam, that may be appropriate—but only as directed and once the seizure subsides enough to allow safe administration.

C. Place a tongue blade in the child's mouth to prevent aspiration.

Inserting objects into the mouth during a seizure is dangerous and can cause choking, dental injury, or aspiration. It is an outdated and unsafe practice.

D. Carry the child to the car and then call 911

Moving the child during a seizure can increase the risk of injury. It is safer to keep the child on the ground in a safe position, monitor the duration of the seizure, and call emergency services immediately if the seizure is prolonged or unusual.

Correct Answer:

C) 0.9% sodium

Explanation:

For blood transfusions, the recommended IV solution is 0.9% sodium chloride (normal saline). This solution is compatible with blood products and helps to maintain the integrity of red blood cells during the transfusion. Other solutions such as Lactated Ringers or those containing dextrose may cause hemolysis or clotting, making them unsuitable for use with blood products.

Why other options are wrong:

A) Lactated Ringers: This solution contains calcium, which can cause clotting when mixed with blood products. It is not recommended for use with blood transfusions.

B) 5% dextrose in 0.9% sodium chloride: This solution contains glucose, which could cause red blood cells to lyse or rupture when transfused, making it incompatible for blood transfusion.

D) 5% dextrose in 0.45% sodium chloride: Similar to the previous option, this solution contains glucose, which could lead to hemolysis of red blood cells, making it unsuitable for blood transfusions.

Correct Answer

A. Altered fetal cerebral blood flow

Explanation

Early decelerations in the fetal heart rate are most commonly caused by head compression during contractions, which alters fetal cerebral blood flow. This compression typically occurs when the presenting part of the fetus pushes against the cervix, resulting in a decrease in fetal heart rate. The deceleration starts early in the contraction and mirrors its shape, returning to baseline before the contraction ends. Early decelerations are generally considered benign and do not indicate fetal distress.

Why other options are wrong

B. Umbilical cord compression

Umbilical cord compression usually results in variable decelerations, not early decelerations. These decelerations often occur abruptly with the onset of the contraction and can be associated with changes in fetal heart rate that are variable in duration and intensity.

C. Uteroplacental insufficiency

Uteroplacental insufficiency is typically associated with late decelerations, not early decelerations. Late decelerations occur after the peak of the contraction and may indicate a lack of oxygen reaching the fetus due to placental dysfunction.

D. Spontaneous rupture of membranes

Spontaneous rupture of membranes (SROM) can sometimes lead to complications like cord prolapse or infection, but it does not directly cause early decelerations. The timing and pattern of decelerations are more strongly linked to head compression than to SROM.

Correct Answer

A. Respiratory distress

B. Fever

D. Pruritus

Explanation

During a blood transfusion, respiratory distress, fever, and pruritus (itching) are all potential signs of an adverse transfusion reaction. These can indicate allergic reactions, febrile non-hemolytic reactions, or even more serious conditions such as acute hemolytic reactions or transfusion-related acute lung injury (TRALI). The nurse must immediately stop the transfusion if any of these occur, assess the patient, and notify the provider. Prompt intervention is necessary to prevent worsening of the reaction.

Why other options are wrong

C. Tinnitus

Tinnitus (ringing in the ears) is not a typical or significant sign of a transfusion reaction. It may occur in other unrelated conditions, but it is not a known hallmark symptom of transfusion-related complications. Therefore, it does not warrant stopping the transfusion unless accompanied by other concerning signs.

Correct Answer

B. "I have started using salt substitutes to lower my sodium intake."

Explanation

Salt substitutes often contain potassium chloride, which can increase potassium levels in patients with chronic kidney disease (CKD). This can be dangerous, as elevated potassium levels (hyperkalemia) can lead to serious complications, including heart arrhythmias. Therefore, using salt substitutes is generally not recommended for CKD patients unless specifically instructed by the healthcare provider.

Why other options are wrong

A. "I keep a log of my fluid intake throughout the day."

This is an appropriate action for a patient on dialysis. Monitoring fluid intake is essential to avoid fluid overload, which can exacerbate kidney problems and affect dialysis outcomes. Keeping track of fluid intake helps in managing the patient's condition effectively.

C. "I began eating scrambled eggs for breakfast instead of bananas."

This statement indicates a correct dietary modification, as bananas are high in potassium, which should be limited in CKD. Scrambled eggs are a better alternative, as they are a good source of protein but low in potassium.

D. "I stopped drinking a can of cola before bed each night."

This is another positive dietary modification. Cola beverages typically contain high levels of phosphates and sugars, which are not recommended for patients with CKD. Stopping the consumption of cola helps to manage the patient's phosphate levels and overall health.

Correct Answer

B.) "This medication will make me feel very ill if alcohol is ingested within 12 hours of taking this medication."

Explanation

Disulfiram (Antabuse) works by causing an adverse reaction when alcohol is consumed, leading to symptoms like nausea, vomiting, and flushing. The patient must understand that they should avoid alcohol in all forms, including in food and medications, for at least 12 hours after taking disulfiram to avoid these unpleasant effects.

Why other options are wrong

A.) "This medication will decrease my craving for alcohol and help with alcohol detoxification."

Disulfiram does not help with alcohol cravings or detoxification. It works by creating a physical deterrent to alcohol consumption, causing severe reactions if alcohol is ingested, but it does not directly affect cravings.

C.) "I will be sure to avoid drinking alcohol but may still consume foods that contain alcohol."

This is incorrect because the patient should avoid all sources of alcohol, including foods that contain alcohol, to prevent a reaction with disulfiram.

D.) "If I forget to take a dose of this medication, I will double the next dose."

Doubling the dose if a dose is missed could lead to dangerous side effects. The proper action is to take the next dose as scheduled and not to double up. The patient should be instructed on how to handle missed doses.

Correct Answer

B. Delay hanging the blood and notify the physician

Explanation

A fever of 100.6°F indicates that the client has a potential infection or inflammatory process. The nurse should delay the transfusion and notify the physician to assess the underlying cause of the fever. Blood transfusions should not be started when the client has a fever, as it could increase the risk of transfusion reactions or mask a reaction.

Why other options are wrong

A. Begin the transfusion as prescribed

Starting a blood transfusion while the client has a fever may increase the risk of complications, including transfusion reactions. It is important to first address the underlying cause of the fever before proceeding with the transfusion.

C. Administer an antihistamine and begin the transfusion

Administering an antihistamine does not address the underlying cause of the fever, and starting the transfusion with a fever may lead to complications. The fever should be evaluated by the physician before any further actions are taken.

D. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

Administering acetaminophen may lower the fever but does not address the root cause of the fever. It is important to delay the transfusion and notify the physician to determine whether the fever is due to an underlying condition that needs further treatment.

Correct Answer

A) Chooses a puncture site in the center of the finger pad.

Explanation

The best site for blood glucose testing is on the side of the fingertip, not the center of the finger pad, as the center contains more nerve endings, which can lead to discomfort. Additionally, puncturing the center of the finger pad can result in inaccurate readings or increased discomfort.

Why other options are wrong

B) Washes hands with soap and water to cleanse the site to be used.

This is the correct practice. Washing hands before testing is important to ensure that the blood sample is not contaminated by food, sugar, or other substances that could alter the glucose reading.

C) Warms the finger before puncturing the finger to obtain a drop of blood.

This is an appropriate action. Warming the finger increases blood flow and helps obtain a sufficient sample for testing, especially if the patient has cold or poor circulation.

D) Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

This is also correct. A blood glucose level of 110 mg/dL is considered within the normal range for a non-fasting individual, and it reflects good control of diabetes, depending on the time of day and when the last meal was consumed.

Correct Answer

A. Start chest compressions

Explanation

When a patient is found unresponsive without respirations or a pulse, the nurse should immediately begin chest compressions as the first step in cardiopulmonary resuscitation (CPR). According to the American Heart Association guidelines, starting high-quality chest compressions promptly is the priority in cardiac arrest situations because it helps maintain circulation to vital organs. Delays in initiating compressions can result in poor outcomes and decreased chances of survival.

Why other options are wrong

B. Give breaths with a manual resuscitator bag

Although providing ventilations is important during CPR, it is not the first priority. Chest compressions should be started immediately, and breaths are added after the initiation of compressions or once a secure airway is established. Focusing on breaths first delays circulation and reduces the effectiveness of early resuscitation efforts.

C. Establish an airway

Establishing an airway is a critical component of CPR, but it follows the initiation of chest compressions. The current guidelines emphasize starting with compressions to maintain perfusion. Airway management is important but should not precede the first round of chest compressions when a patient has no pulse or respirations.

D. Administer oxygen

Administering oxygen is not the first step in a cardiac arrest situation. Oxygen delivery is useful after CPR is initiated and the airway is managed. Without circulation, oxygen cannot be effectively transported to tissues, so chest compressions must come first to restore perfusion.