Nokea
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
- A. Dietary intake history
- B. Motor milestone development
- C. Head circumference
- D. Skin turgor
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
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The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
- A. Administer oxygen.
- B. Prepare for needle decompression.
- C. Obtain a chest X-ray.
- D. Start an IV line.
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypophosphatemia.
- D. Hypermagnesemia.
- E. Hypocalcemia.
Correct Answer: A, C
Rationale: Diabetic ketoacidosis can cause hypokalemia (insulin shifts potassium) and hypophosphatemia (osmotic diuresis).
Communicating with parents and children about health care has become increasingly significant because:
- A. Consumers of health care cannot keep up with rapid advances in science.
- B. The influence of the media and specialization have increased the complexity of managing health.
- C. Nurse educators have recognized the value of communication.
- D. Clients are more demanding that their rights be respected.
Correct Answer: B
Rationale: Media influence and medical specialization have increased healthcare complexity, making clear communication essential to ensure understanding and informed decision-making.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.
The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?
- A. The Four P's
- B. UBAR
- C. ISBAR
- D. MAUMAR
Correct Answer: C
Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.