The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?

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Question 1 of 5

The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?

Correct Answer: C

Rationale: If evidence of cardiac tamponade is found in a child after heart surgery, it is crucial for the nurse to immediately report this to the physician. Cardiac tamponade is a serious condition where excess fluid or blood accumulates in the pericardial sac, compressing the heart and affecting its ability to pump effectively. Prompt recognition and intervention are essential to prevent potential life-threatening outcomes. The physician would need to assess the child's condition, consider performing procedures to relieve the tamponade such as pericardiocentesis, and provide appropriate treatment to stabilize the child. Delaying reporting and action in cases of cardiac tamponade can lead to further complications and worsen the child's condition.

Question 2 of 5

A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?

Correct Answer: D

Rationale: Option D is the most appropriate action in this scenario because it demonstrates empathy and opens the door for the patient to express his concerns. By acknowledging the patient's withdrawn behavior and directly inquiring about his feelings regarding the diagnosis or treatment, the nurse creates an opportunity for the patient to share his thoughts and concerns. This open-ended question allows the patient to express himself without any assumptions or judgments. It shows that the nurse is attentive, supportive, and willing to listen to the patient's emotional needs during this challenging time.

Question 3 of 5

The nurse needs to administer an IM injection of 2.4 million units of penicillin G. it is supplied in a vial of 5,000,000 units of powder for injection. Instructions state to dilute with 8 mL of sterile water. How manu mL should the nurse draw up?

Correct Answer: B

Rationale: To administer an IM injection of 2.4 million units of penicillin G, the nurse should first reconstitute the penicillin powder with sterile water as per the instructions. The vial contains 5,000,000 units of the powder and when diluted with 8 mL of sterile water, the resulting concentration would be:

Question 4 of 5

A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient's diet with:

Correct Answer: D

Rationale: One beef cube typically contains about 800mg of sodium, and 8oz of tomato juice contains approximately 480mg of sodium. Therefore, to provide a total of 1,600mg of sodium daily, the nurse could supplement the patient's diet with one beef cube (800mg sodium) and 12oz of tomato juice (720mg sodium). This combination would effectively provide the required 1,600mg of sodium per day for the patient with abnormal sodium losses.

Question 5 of 5

With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes?

Correct Answer: C

Rationale: Hypokalemia is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes. Potassium is an essential electrolyte for muscle function, including maintaining muscle tone and supporting proper nerve conduction for reflexes. When potassium levels are low, it can lead to muscle weakness, decreased muscle tone, and reduced deep tendon reflexes. With severe diarrhea, potassium is often lost along with fluids, leading to a potential electrolyte imbalance such as hypokalemia. Additionally, hypokalemia can cause cardiac arrhythmias, muscle cramps, and fatigue, further supporting the presence of this electrolyte imbalance in Ms. CC.

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