Nokea
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
- A. The child asks to have friends visit.
- B. The child asks to have a teacher bring in homework.
- C. The child's parents state that they need to spend some time with the child's siblings.
- D. The child's parents will not leave the child alone while in the hospital.
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
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The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
- A. Check the client's temperature
- B. Check the client's blood pressure
- C. Check the client's respirations
- D. Check the client's apical pulse
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.
The nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.