Nokea
A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the health care provider
- B. Readjust the traction
- C. Administer the ordered prn medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: Notify the health care provider. The findings are indicative of circulatory impairment. The health care provider must be notified immediately.
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The NA is preparing to provide care for four clients. The nurse should direct the NA to utilize contact precautions for which client?
- A. Client with influenza
- B. Client with mumps
- C. Client with gonorrhea
- D. Client with a draining abscess
Correct Answer: D
Rationale: D: A draining abscess requires contact precautions due to potential infectious drainage. A, B: These require droplet precautions. C: Gonorrhea needs standard precautions.
A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.
The nurse is preparing for a dressing change using surgical aseptic technique. Which action by the nurse is correct when setting up the sterile field?
- A. Dons sterile gloves before opening the package that contains the sterile drape.
- B. Uses alcohol to cleanse a bottle of irrigating solution before placing it on the sterile drape.
- C. Holds an opened sterile package 6 inches above the field to drop the item into the sterile field.
- D. Leaves the sterile field unattended to obtain the correct size of sterile gloves.
Correct Answer: C
Rationale: C: Dropping items from 6 inches above the sterile field maintains sterility by avoiding contact with non-sterile surfaces. A: Sterile gloves are donned after opening the drape. B: Non-sterile bottles cannot be placed on the sterile field. D: Leaving the field unattended risks contamination.
Which information should the nurse reinforce to the parents of a child recently diagnosed with Kawasaki disease?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes.'
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.'
- C. Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent.'
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.'
Correct Answer: C
Rationale: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck.