Nokea
A 3-year-old child had a seizure two days ago when the child's temperature was 105°F. The child has had no previous seizures. Today, the parent and the child are in the physician's office. What should the nurse include when teaching the parent?
- A. The child now has epilepsy and will need long-term care for this condition.
- B. If the child develops a fever over 101°F, administer ibuprofen.
- C. Make sure the child drinks plenty of water every day.
- D. Call the physician's office immediately if the child develops a temperature over 100.4°F.
Correct Answer: B
Rationale: A febrile seizure at 105°F in a 3-year-old without prior seizures suggests a one-time event; ibuprofen for fevers above 101°F helps prevent recurrence, while epilepsy or immediate reporting is premature.
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The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
The nurse is reinforcing teaching about nutrition with the parents of a 6-year-old client with cystic fibrosis. Which recommended diet should the nurse include?
- A. High calorie, high protein
- B. High carbohydrate, low fiber
- C. Low fat, low sodium
- D. Low phosphate, low protein
Correct Answer: A
Rationale: Cystic fibrosis requires a high-calorie, high-protein diet to support growth and compensate for malabsorption. Other diets do not meet the increased nutritional demands.
The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:
- A. Stop the administration of the enema.
- B. Lower the height of the enema container.
- C. Clamp the enema tubing and withdraw it slowly.
- D. Advance the tubing 1-2 inches.
Correct Answer: B
Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
- A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning
- B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning
- C. Discard urine and container, have client void, add urine to new container, and then restart test
- D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM
Correct Answer: B
Rationale: Discarding a specimen invalidates the 24-hour collection, requiring a restart to ensure accurate results. Adding volume, restarting mid-collection, or relabeling compromise test integrity.
While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.
- A. Assist with active and passive range of motion exercises
- B. Change bed linens while logrolling the client from side to side
- C. Check the color and temperature of the affected extremity
- D. Reapply pneumatic compression device after bathing the client
- E. Remind the client to use the incentive spirometer
Correct Answer: A,D,E
Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.