Nokea
A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?
- A. I am so tired. I want Mommy to hold me.'
- B. Look at my new hat. I wear it all the time. It's pretty.'
- C. See all my bruises. They are funny colors.'
- D. I wish I could eat pizza, but everything makes me throw up.'
Correct Answer: B
Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.
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A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which directions are essential for the nurse to reinforce? Select all that apply.
- A. Avoid alcohol while taking this medication
- B. Perform vaginal douche for 7-10 days
- C. Use birth control pills to prevent infection recurrence
- D. Your partner(s) must be treated simultaneously
- E. Your urine can change to a deep red-brown color
Correct Answer: A,D,E
Rationale: Metronidazole treatment for trichomoniasis requires specific instructions. Avoiding alcohol (A) prevents a disulfiram-like reaction. Partner treatment (D) is essential to prevent reinfection, as trichomoniasis is sexually transmitted. Urine discoloration (E) is a possible side effect to anticipate. Douching (B) is not recommended, as it disrupts vaginal flora. Birth control pills (C) do not prevent recurrence of this infection.
All of the following individuals live at home with their families. Which of the following persons is least at risk for abuse?
- A. An 82-year-old woman who is incontinent and bosses people around
- B. An 80-year-old man who is ambulatory with help following a brain attack
- C. A 78-year-old woman who asks for help with all of her activities of daily living
- D. A 75-year-old man who wanders at night and frequently yells out
Correct Answer: B
Rationale: The ambulatory man with minimal dependency is least likely to be abused, as he retains some independence. Incontinence, high dependency, or disruptive behavior increase vulnerability.
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.
- A. Educate newly admitted client on the importance of using the call light for assistance
- B. Place the bedside commode as close to the bed as possible
- C. Remind client to change position slowly
- D. Report observations of changes in client’s condition immediately
- E. Report whether client is using correct gait and balance while ambulating with walker
Correct Answer: B,C,D
Rationale: UAP can place commodes (B), remind about slow position changes (C), report condition changes (D), and observe gait (E). Education (A) requires nursing judgment, unsuitable for delegation.
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
- A. Ataxia and coarse hand tremors
- B. Vomiting, diarrhea and lethargy
- C. Pruritus, rash and photosensitivity
- D. Electrolyte imbalance and cardiac arrhythmias
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.