Nokea
A 4-year-old is brought to the emergency department after ingesting an unknown number of aspirin pills. The child is sniffling and crying quietly. The practical nurse anticipates initially assisting with the implementation of which treatment?
- A. Activated charcoal
- B. Gastric lavage
- C. Sodium bicarbonate
- D. Syrup of ipecac
Correct Answer: A
Rationale: Activated charcoal is the initial treatment for aspirin ingestion to prevent absorption, if within 1-2 hours.
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The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.
- A. Dysuria
- B. Jaundice
- C. Low back pain
- D. Night sweats
- E. Weight loss
- F. Purulent or blood-tinged sputum
Correct Answer: D,E,F
Rationale: Night sweats, weight loss, and purulent/blood-tinged sputum are hallmark symptoms of pulmonary tuberculosis.
The home health nurse is contributing to the plan of care for a 1-year-old client recently diagnosed with failure to thrive. Which of the following interventions should the nurse recommend including in the client's plan of care? Select all that apply.
- A. Assess overall parenting skills and access to resources
- B. Observe both the client and the parents during feedings
- C. Monitor the client's height, weight, and head circumference
- D. Ask the parents about the client's dietary intake over the past 24 hours
- E. Discuss with the parents the need to insert a nasogastric tube for enteral feedings
Correct Answer: A,B,C,D
Rationale: Assessing parenting, observing feedings, monitoring growth, and reviewing intake identify causes of failure to thrive. Nasogastric tubes are not initially indicated.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider?
- A. Fever
- B. Irritability
- C. Joint pain
- D. Skin peeling
Correct Answer: A
Rationale: Fever in Kawasaki disease may indicate persistent inflammation or complications, requiring immediate reporting.