Nokea
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.
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Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
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.
Which of the following clients should the nurse assess first?
- A. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
- B. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
- C. An adolescent who has sickle cell anemia and slurred speech
- D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change
Correct Answer: C
Rationale: The correct choice is C. The nurse should assess the adolescent with sickle cell anemia and slurred speech first because slurred speech could indicate a potential stroke or other serious neurological complication related to sickle cell disease. It is crucial to prioritize neurological symptoms as they may lead to life-threatening complications if not addressed promptly. Assessing for signs of stroke and providing immediate intervention is essential in this situation. Choices A, B, and D involve pain management and wound care, which are important but not as urgent as addressing potential neurological complications. Therefore, assessing the client with slurred speech is the priority to ensure timely and appropriate intervention.
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
Which of the following statements should the nurse include?
- A. Notify the provider if your child has dark brown blood between their teeth.
- B. Encourage your child to drink liquids through a straw.
- C. Notify the provider if your child is swallowing frequently.
- D. Encourage your child to clear their throat as needed.
Correct Answer: C
Rationale: The correct answer is C, "Notify the provider if your child is swallowing frequently." This statement is important as frequent swallowing may indicate potential issues such as aspiration or difficulty swallowing. It is crucial for the nurse to be aware of this symptom to ensure timely intervention.
Choice A is incorrect because dark brown blood between the teeth is not a typical symptom that would require immediate notification to the provider. Choice B is also incorrect as encouraging a child to drink through a straw may not be relevant to the situation at hand. Choice D is incorrect as clearing the throat as needed may not address the underlying issue of frequent swallowing.