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A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.
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When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.
An oncology nurse educator is speaking to a women's group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
- A. Mammography is the most reliable method for detecting breast cancer.
- B. Breast cancer is the leading killer of women of childbearing age.
- C. Breast cancer requires a mastectomy.
- D. Men can develop breast cancer.
Correct Answer: D
Rationale: While all the statements made by the audience members may have been common misconceptions, the only one that is accurate is that men can develop breast cancer. Although it is less common in men than in women, breast cancer can still affect males. It is important for everyone to be aware of the risks and symptoms of breast cancer, regardless of gender.
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
- A. "The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!"
- B. "His stroke has made him less inhibited. We'll see if we can find a male assistant to help him."
- C. "We have to take care of all patients equally, even the dirty old men."
- D. "He didn't mean anything by it, just ignore it."
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
A nurse manager at a home-care agency is planning a continuing education program for the home-care staff nurses. Which type of continuing education program should the nurse manager plan?
- A. On-line training modules
- B. A structured written teaching module each nurse completes individually
- C. A workshop training day, with a professional speaker, where nurses can interact with each other
- D. One-on-one continuing education training with each nurse
Correct Answer: C
Rationale: A workshop training day with a professional speaker where nurses can interact with each other would be the most beneficial type of continuing education program for home-care staff nurses. This type of program allows for interactive learning and the opportunity for nurses to engage in discussions, ask questions, and share experiences with each other. It promotes a collaborative learning environment, fosters teamwork, and enhances communication among the staff. Additionally, bringing in a professional speaker can provide valuable insights and expertise on relevant topics, further enriching the education experience for the nurses. Overall, a workshop training day would be a more engaging and effective approach to continuing education for the home-care staff nurses compared to the other options listed.
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
- A. Notify the doctor
- B. Look for other signs of abuse
- C. Recognize this as a normal finding
- D. Ask about a family history of Tay-Sachs disease
Correct Answer: C
Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.