Nokea
The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?
- A. When the course of antibiotics is complete
- B. When a negative CNS culture is obtained
- C. When the antibiotics have been initiated for 24 hours
- D. When the child has no symptoms of the disease
Correct Answer: C
Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.
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While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?
- A. Prepare for cardiac defibrillation.
- B. Apply cardiac monitor leads.
- C. Obtain troponin serum levels.
- D. Palpate the client's artery.
Correct Answer: D
Rationale: Palpating the client's artery is the priority intervention in this scenario because it helps determine if there is a pulse, which is crucial information in emergency situations like this. If the client is pulseless, immediate initiation of CPR is necessary. Applying cardiac monitor leads or obtaining troponin serum levels can wait until the presence of a pulse is confirmed. Cardiac defibrillation is not indicated without first assessing the client's pulse and cardiac rhythm.
The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
- A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
- B. Increase fluid intake to stay hydrated
- C. Consume a high-sodium diet to retain fluids
- D. Engage in vigorous exercise daily
Correct Answer: A
Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.
The family of a newly admitted child with cystic fibrosis is educated by the nurse that the treatment will be centered on what therapy?
- A. Chest physiotherapy
- B. Mucus-drying agents
- C. Prevention of diarrhea
- D. Insulin therapy
Correct Answer: A
Rationale: The correct answer is A: Chest physiotherapy. In cystic fibrosis, chest physiotherapy and aerosol medications are fundamental components of treatment to help clear mucus from the lungs, reduce the risk of infections, and improve breathing. Mucus-drying agents (Choice B) are not typically used in the treatment of cystic fibrosis. Prevention of diarrhea (Choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (Choice D) is not relevant to cystic fibrosis, as it is a treatment for diabetes.
Which is a long-term complication of cleft lip and palate?
- A. Cognitive impairment
- B. Altered growth and development
- C. Faulty dentition
- D. Physical abilities
Correct Answer: C
Rationale: The correct answer is C, 'Faulty dentition.' The older child with cleft lip and palate may experience psychological difficulties due to the cosmetic appearance of the defect, issues with impaired speech, and faulty dentition. This can lead to problems with dental alignment, crowding, missing or malformed teeth, and other dental issues. Choices A, B, and D are incorrect as cognitive impairment, altered growth and development, and physical abilities are not typically considered long-term complications of cleft lip and palate.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?
- A. Applesauce
- B. White rice
- C. Coffee
- D. Bananas
Correct Answer: C
Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.