Nokea
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.
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Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
Available is diphenhydramine 50 mg/mL. How many ml should the nurse administer? (Round to the nearest tenth)
Correct Answer: 0.6
Rationale: To determine the correct amount of diphenhydramine to administer, we can use the formula: Volume (mL) = Desired dose (mg) / Concentration (mg/mL). In this case, the desired dose is 50 mg and the concentration is 50 mg/mL. So, Volume = 50 mg / 50 mg/mL = 1 mL. Since we need to round to the nearest tenth, the correct answer is 0.6 mL. This is because 1 mL is equivalent to 50 mg, and since we only need to administer 50 mg, we use 0.6 mL. Other choices are incorrect as they do not adhere to the calculation based on the concentration and desired dose.
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
Which of the following actions should the nurse take?
- A. Inform the client to contact the pharmacy regarding any questions related to the medication.
- B. Provide instructions to the client's parent with the client present.
- C. Instruct the client's parents to write down the information that is being provided.
- D. Ask how the client prefers to learn new information.
Correct Answer: D
Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.
Which of the following recommendations should the nurse make?
- A. Store opened vials of insulin for up to 60 days.
- B. Follow up with physical therapy.
- C. Consult with a nutritionist.
- D. Monitor capillary blood glucose daily.
Correct Answer: C
Rationale: The correct recommendation is to consult with a nutritionist (Choice C). This is crucial in diabetes management as a nutritionist can provide personalized dietary guidance to help control blood sugar levels. By consulting with a nutritionist, the patient can learn about healthy eating habits, portion control, and meal planning tailored to their specific needs. This can lead to better blood glucose control and overall improved health outcomes. Storing opened vials of insulin for 60 days (Choice A) is incorrect as insulin should be discarded after a certain period to ensure its effectiveness. Following up with physical therapy (Choice B) may be beneficial for other health conditions but is not specifically related to managing diabetes. Monitoring capillary blood glucose daily (Choice D) is important but does not address the need for dietary adjustments which a nutritionist can provide.