Nokea
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
- A. Use a cool air vaporizer with plain water.
- B. Use saline nose drops and then a bulb syringe.
- C. Blow into the child's mouth to clear the infant's nose.
- D. Administer a nonprescription vasoconstrictive nose spray.
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
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When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Nausea.
- B. Gingival hyperplasia.
- C. Rash.
- D. Drowsiness.
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
- A. Resonance
- B. Flatness
- C. Tympany
- D. Dullness
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.
After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?
- A. Play a game of checkers with the client in his room.
- B. Invite the client to attend a group session with the nurse.
- C. Invite the client to go for a walk with the nurse and one other client.
- D. Talk with the client in a corner of the crafts room.
Correct Answer: C
Rationale: A walk with the nurse and one other client provides a low-pressure social interaction, helping the client gradually build comfort with others while respecting his anxiety about crowds.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.