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A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm.The white blood cell count is 16,000/mm³. Which of the following should the nurse identify as the immediate priority nursing diagnosis?
- A. Anxiety related to need for immediate and unplanned hospitalization.
- B. Risk for injury (airway obstruction) related to epiglottal edema.
- C. Impaired gas exchange related to excessive respiratory effort.
- D. Ineffective airway clearance related to aspiration.
Correct Answer: B
Rationale: The symptoms indicate epiglottitis, with a high risk of airway obstruction due to epiglottal edema, making this the priority diagnosis.
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The nurse is caring for a client with a history of burns. Which of the following nutritional interventions should be included in the plan of care?
- A. High-protein, high-calorie diet.
- B. Low-sodium diet.
- C. Low-fat diet.
- D. High-fiber diet.
Correct Answer: A
Rationale: A high-protein, high-calorie diet supports tissue repair and energy needs in burn recovery.
The nurse manager is developing a 'read-back' procedure to reduce medication administration errors. Which of the following are purposes of the 'read-back' requirement? Select all that apply.
- A. To prohibit orders and test results from being communicated verbally or by telephone.
- B. To ensure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
- C. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.
- D. To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone.
- E. To encourage the use of electronic medical records.
Correct Answer: B,C,D
Rationale: Read-back ensures clarity, confirmation, and authorized communication of verbal orders, reducing errors. It does not prohibit verbal orders or mandate electronic records.
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
Which of the following is an adverse effect to therapeutic radiation therapy?
- A. Fibrosis
- B. Alopecia
- C. Oral dryness
- D. Xerostomia
Correct Answer: D
Rationale: Xerostomia (dry mouth) is a common adverse effect of radiation therapy, particularly when the head or neck is irradiated, due to damage to salivary glands.
A client with the diagnosis of chronic kidney disease (CKD) has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly when the client states that he or she will do what when preparing vegetables?
- A. Eat only fresh vegetables.
- B. Boil them and discard the water.
- C. Use only salt substitutes to season.
- D. Buy frozen vegetables whenever possible.
Correct Answer: B
Rationale: The potassium content of vegetables can be reduced by boiling them and discarding the cooking water. Clients with CKD should avoid the use of salt substitutes altogether because they tend to be high in potassium content.