Nokea
A 2-month-old boy with a temperature of $102°F (39°C) is brought to the emergency department by his mother.
- A. What should the nurse’s response be based on regarding a fever in a 2-month-old one week after a DPT immunization?
- B. If a fever does occur in a child after a DPT, it usually occurs within the first 2 hours.
- C. An elevated temperature is very rarely seen in a child after a DPT immunization.
- D. If there is a fever after a DPT, it is usually low-grade and appears within the first 48 hours.
- E. The child’s high fever is a direct response to the DPT immunization and should be treated.
Correct Answer: C
Rationale: A low-grade fever within 24-48 hours is a common response to DPT immunization. A high fever (102°F) one week later is unlikely related to the immunization and should be reported to a physician for evaluation, possibly indicating another cause.
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The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The first thing the RN should do before the delegation of care is
- A. Provide a time-frame for the completion of the client care
- B. Assure the PN that the RN will be available for assistance
- C. Ask about prior experience with similar clients
- D. Review the specific procedures unique to the assignment
Correct Answer: C
Rationale: The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN’s prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for the assigned clients.
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular (AV) wires removed later in the day.
- B. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
- C. A patient who is one-day postoperative and has an epidural catheter in place.
- D. A patient who is being evaluated for a heart transplant.
Correct Answer: C
Rationale: Strategy: Determine which patient is the least stable. (1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct-epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority
The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
- A. Rotation of injection sites
- B. Insulin mixing and preparation
- C. Daily blood sugar monitoring
- D. Regular high protein diet
Correct Answer: C
Rationale: Daily blood sugar monitoring. Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.