Nokea
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
- A. Playing with toys in a back yard flower garden
- B. Eating small amounts of grass while playing 'farm'
- C. Playing with cars on the pavement near burning leaves
- D. Throwing a ball to a neighborhood child who has poison ivy
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
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The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after use.
- C. Stop the medication if symptoms improve.
- D. Avoid regular asthma follow-ups.
Correct Answer: B
Rationale: Rinsing the mouth prevents oral thrush, a fluticasone side effect. Options A, C, and D are incorrect.
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
A client has a history of oliguria, hypertension, and peripheral edema.
- A. Which nutrient should be restricted in a client with oliguria, hypertension, and peripheral edema (BUN 25, K+ 0 mEq/L)?
- B. Protein.
- C. Fats.
- D. Carbohydrates.
- E. Magnesium.
Correct Answer: A
Rationale: Oliguria, hypertension, and edema suggest renal impairment, where protein restriction reduces metabolic waste (e.g., urea nitrogen) that the kidneys cannot excrete. Fats and carbohydrates are encouraged, and magnesium restriction is not indicated.
A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.
The appropriate nursing action would be to
- A. put the client in full restraints.
- B. decrease environmental stimulation.
- C. call the security guards.
- D. administer a PRN dose of chlorpromazine (Thorazine).
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client
- A. Should remain on bed rest in a semi-Fowler's position
- B. Should alternate ambulation with bed rest with legs elevated
- C. May ambulate and sit in chair as tolerated
- D. May ambulate as tolerated and remain in semi-Fowlers position in bed
Correct Answer: B
Rationale: Should alternate ambulation with bed rest with legs elevated. Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites.