Nokea
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast.
- B. Provide crayons and a coloring book for play activity.
- C. Increase her intake of high-calorie foods for healing.
- D. Tuck a disposable diaper beneath the cast at the perineal opening.
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
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A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
- A. Slow the infusion rate
- B. Make sure the client is well hydrated
- C. Record the intake and output every shift
- D. Tell the client to report ringing in the ears
Correct Answer: B
Rationale: Adequate hydration is critical to prevent cisplatin-induced nephrotoxicity by promoting renal excretion of the drug.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.
A 54-year-old female is brought into the ED by her spouse. The client's spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
- A. calcium 7.2 mg/dL
- B. alkaline phosphatase 120 IU/L
- C. sodium 143 mEq/L
- D. creatinine 0.8 mg/dL
Correct Answer: A
Rationale: Hypocalcemia (calcium 7.2 mg/dL, normal 8.5–10.2) can cause muscle stiffness and anxiety, requiring immediate notification. Other results are normal.
The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?
- A. placing familiar objects such as family photos, a clock, and a personal calendar on the wall
- B. asking the physician to order restraints so the client does not try and get up
- C. asking the client's daughter to stay overnight so the client is comforted by a familiar face
- D. moving the client to a better staffed floor, so she can be watched more carefully
Correct Answer: A
Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.