Nokea
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
- A. Dry mucous membranes
- B. Decreased urine output
- C. Sunken fontanelles
- D. Tachycardia
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
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A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?
- A. Yes, use the inhaler immediately for these symptoms.'
- B. No, this drug is a maintenance drug, not a rescue inhaler.'
- C. Use the inhaler 5 minutes before you exercise to prevent the wheezing.'
- D. This inhaler is for allergic rhinitis, not asthma.'
Correct Answer: B
Rationale: Salmeterol is a long-acting beta-agonist used for asthma maintenance, not for acute symptoms like wheezing during exercise. A rescue inhaler, such as albuterol, is appropriate for acute symptoms.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
- A. I need to avoid rotating breast-feeding positions so that the nipple will toughen.
- B. I need to stop nursing during the period of nipple soreness to allow the nipples to heal.
- C. I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore.
- D. I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me.
Correct Answer: D
Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple. The remaining options are incorrect statements.
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
- A. You shouldn't let yourself get so upset
- B. Don't worry about them. They don't mean any harm
- C. Look. They seem to be having fun
- D. They're laughing at a joke John told. They aren't laughing at you
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?
- A. Cooled.
- B. Humidified.
- C. At a low flow rate.
- D. Through nasal cannula.
Correct Answer: C
Rationale: Low flow rate oxygen prevents CO2 retention in emphysema clients, reducing the risk of depressed ventilation.