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A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?
- A. Assess the client's temperature.
- B. Place a mask on the client.
- C. Obtain a chest X-ray per protocol.
- D. Determine the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.
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A client with a head injury reports severe nausea. What is the nurse's priority action?
- A. Administer anti-nausea medication as prescribed.
- B. Prepare the client for a CT scan.
- C. Elevate the head of the bed and provide an emesis basin.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?
- A. Had a cold and ear infection for the past two days
- B. Missed a dose of insulin
- C. Did not follow dietary restrictions
- D. Overexerted during exercise
Correct Answer: A
Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.
The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?
- A. Assess a client's pain level post-surgery
- B. Turn and reposition a client with a total hip replacement
- C. Administer a dose of insulin per sliding scale
- D. Change a postoperative dressing
Correct Answer: B
Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.
The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
- A. Platelet count and red blood cell count.
- B. White blood cell count and sputum culture.
- C. Hemoglobin A1c and glucose tolerance test.
- D. Arterial blood gases and serum electrolytes.
Correct Answer: B
Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occur.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct Answer: B
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.