Nokea
A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct Answer: D
Rationale: Remove the child's toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child's mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.
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The nurse is reinforcing teaching with a client who has a new prescription for Rh immunoglobulin. The client has an Rh-negative blood type and gave birth 24 hours ago to a newborn who has an Rh-positive blood type. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I need the medication now because the dose I received during pregnancy was ineffective
- B. I can receive the medication at my follow-up appointment in 6 weeks
- C. I need to have a blood specimen obtained in 3 months to verify that the medication was effective
- D. I will receive the medication to prevent my body from forming antibodies
Correct Answer: D
Rationale: Rh immunoglobulin prevents antibody formation against Rh-positive fetal blood, given within 72 hours postpartum. The prenatal dose is separate, 6 weeks is too late, and 3-month testing is not standard.
Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
The nurse is teaching the client the appropriate way to use a metered dose inhaler. Which observation indicates the client needs additional teaching?
- A. The client takes a deep breath while depressing the canister
- B. The client holds the canister two finger widths from the mouth
- C. The client waits 30 seconds before repeating the inhalation
- D. The client exhales slowly and deeply
Correct Answer: C
Rationale: When using a metered dose inhaler, the client should wait 1-2 minutes between puffs to ensure proper absorption, not 30 seconds. Answer C indicates a need for additional teaching. Answers A, B, and D describe correct techniques for inhaler use.
The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?
- A. I am trying to find makeup to cover my unattractive, ruddy facial complexion
- B. I massage my sore leg to help bring the swelling down
- C. I take low-dose aspirin to relieve my occasional headaches
- D. My skin itches so severely, and no lotion or cream seems to help
Correct Answer: B
Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.
The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.