Nokea
A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child?
- A. Gastrointestinal bleeding
- B. Growth retardation
- C. Neurocognitive impairment
- D. Severe liver injury
Correct Answer: C
Rationale: Elevated lead levels primarily cause neurocognitive impairment in children, affecting brain development and leading to learning and behavioral issues. Gastrointestinal bleeding, growth retardation, and liver injury are less common or less severe consequences.
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A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply.
- A. Check the pins every 4 hours and turn the bolt clockwise to tighten loose pins
- B. Maintain client on bed rest until the device is removed
- C. Notify the registered nurse immediately of pin site drainage or increased pain
- D. Perform neurovascular checks every 2-4 hours for 24 hours
- E. Perform sterile pin care per institutional policy
Correct Answer: C,D,E
Rationale: Notifying the RN of drainage or pain, performing neurovascular checks, and sterile pin care prevent complications like infection or neurovascular compromise. Tightening pins is not a nursing task, and bed rest is not always required, depending on the care plan.
An adult who is hospitalized with congestive heart failure is receiving an intravenous infusion. The nurse is checking the IV. Which of the following is of greatest concern to the nurse?
- A. The insertion site
- B. The volume infused
- C. The frequency with which the tubing is changed
- D. The presence of a flashback
Correct Answer: A
Rationale: The insertion site is critical to assess for infection, infiltration, or phlebitis, the greatest concern to prevent IV complications in heart failure.
In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
- A. Age 40 years
- B. Lactose intolerance
- C. Family history of breast cancer
- D. Use of cocaine on weekends
Correct Answer: D
Rationale: Use of cocaine on weekends. Cocaine use is harmful to the breastfed infant, even with intermittent use.
Which isolation procedure will be followed for secretions and blood?
- A. Respiratory
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet
Correct Answer: B
Rationale: Standard Precautions apply to all body fluids except sweat, including blood and secretions, to reduce transmission risk in all client interactions. Safety and Infection Control