Nokea
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.
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A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?
- A. Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body.
- B. This tumor can be treated effectively with chemotherapy.
- C. Surgery is always required to remove this type of tumor.
- D. This condition is always fatal within a few months.
Correct Answer: A
Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Iron
Correct Answer: C
Rationale: The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism; therefore, they are incorrect.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.
Medication administration record
Allergies: No known allergies
Sliding-Scale Serum Glucose Level Regular Insulin Dose
<150 mg/dL (<8.3 mmol/L) 0 units
150-199 mg/dL (8.3-11 mmol/L) 3 units
200-249 mg/dL (11.1-13.8 mmol/L) 5 units
250-299 mg/dL (13.9-16.6 mmol/L) 7 units
≥300 mg/dL (≥16.7 mmol/L) 9 units and notify the health care provider
The nurse is caring for a client who has a prescription for 25 units of NPH insulin and sliding-scale regular insulin. The client's serum glucose level is 237 mg/dL (13.2 mmol/L). How many total units of insulin should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 29
Rationale: Assuming a sliding-scale protocol (e.g., 4 units for 201-250 mg/dL), 25 units NPH + 4 units regular = 29 units total.