Nokea
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To reduce fear of the unknown
- B. To keep the child calm
- C. To establish a trusting relationship
- D. To prevent or minimize separation anxiety
Correct Answer: D
Rationale: Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.
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The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?
- A. Use albuterol first, then ipratropium.'
- B. Use ipratropium first, then albuterol.'
- C. Use both inhalers simultaneously.'
- D. Use only one inhaler per day.'
Correct Answer: A
Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to increase her caloric intake.
- D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:
- A. I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.
- B. It is not too much trouble. This is the best way to manage urination.
- C. OK. I'll ask your physician if we can replace the Foley.
- D. You need to learn this because your doctor ordered it.
Correct Answer: A
Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Fever
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.