Nokea
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
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Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
Which of the following immunizations should the nurse plan to administer?
- A. Measles, mumps, and rubella (MMR)
- B. Varicella (VAR)
- C. Rotavirus (RV)
- D. Herpes zoster
- E. Human papillomavirus (HPV4)
Correct Answer: A,B
Rationale: The correct answer is A (MMR) and B (VAR). These immunizations are recommended for certain age groups to prevent measles, mumps, rubella, and varicella. MMR provides protection against three viral infections, while VAR protects against chickenpox. These vaccinations are part of the routine childhood immunization schedule to prevent the spread of these contagious diseases. Rotavirus (C) is given to infants to protect against a common cause of severe diarrhea, while Herpes zoster (D) and Human papillomavirus (E) are not typically administered by nurses in routine practice.
Which of the following safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child might experience mood swings.
- B. I should take my child to the clinic for a weekly blood test.
- C. I should withhold my child's medication before physical activity.
- D. My child might have a decreased appetite.
Correct Answer: A
Rationale: The correct answer is A: "My child might experience mood swings." This statement shows understanding as mood swings can be a side effect of the medication being discussed. It demonstrates awareness of potential effects and indicates readiness to handle them. Choice B is incorrect as weekly blood tests are not typically necessary. Choice C is incorrect as withholding medication before physical activity can be dangerous. Choice D is incorrect as a decreased appetite is not a common side effect.
Specify 2 parameters the nurse should monitor to assess the client's progress.
- A. Number of steatorrhea stools
- B. Intake and output
- C. Respiratory Status (Monitor respiratory)
- D. Presence of periorbital edema
Correct Answer: B,C
Rationale: The correct parameters for the nurse to monitor to assess the client's progress are intake and output (B) and respiratory status (C). Monitoring intake and output is crucial to assess fluid balance and kidney function. Changes in these values can indicate dehydration or fluid overload. Respiratory status should be monitored to assess oxygenation and ventilation, which are essential for tissue perfusion and overall health.
The incorrect choices are A, D, E, F, and G. A (Number of steatorrhea stools) is not directly related to assessing overall client progress. D (Presence of periorbital edema) may be indicative of fluid retention but is not as direct as intake and output monitoring. Choices E, F, and G are not provided, thus not applicable to the question.