Free NCLEX-RN Exam Braindumps (page: 117)

Page 117 of 431

Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

  1. Cover sac with dry sterile dressing
  2. Cover sac with saline-soaked sterile dressing
  3. Do not apply dressing; keep sac open to air
  4. Aspirate any fluid from sac

Answer(s): B

Explanation:

(A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.



Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

  1. Cover sac with dry sterile dressing
  2. Cover sac with saline-soaked sterile dressing
  3. Do not apply dressing; keep sac open to air
  4. Aspirate any fluid from sac

Answer(s): B

Explanation:

(A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.



A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

  1. pH 7.39
  2. White blood cell (WBC) count 10,000 WBCs/mm3
  3. Hematocrit 60%
  4. Bleeding time of 4 minutes

Answer(s): C

Explanation:

(A) Normal pH of arterial blood gases for an infant is 7.35­7.45. (B) Normal white blood cell count in an infant is 6,000­17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%­42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2­7 minutes.



A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

  1. pH 7.39
  2. White blood cell (WBC) count 10,000 WBCs/mm3
  3. Hematocrit 60%
  4. Bleeding time of 4 minutes

Answer(s): C

Explanation:

(A) Normal pH of arterial blood gases for an infant is 7.35­7.45. (B) Normal white blood cell count in an infant is 6,000­17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%­42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease. (D) Normal bleeding time is 2­7 minutes.



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