Nokea
A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?
- A. Teach the client about the importance of hydration
- B. Report the volume of emesis to the healthcare provider
- C. Administer ondansetron hydrochloride (Zofran)
- D. Encourage the client to limit the amount of movement
Correct Answer: C
Rationale: Administering ondansetron (Zofran) will help relieve the vomiting and prevent dehydration, addressing the immediate concern.
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An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs.
- B. I see halos floating around my head.
- C. I have trouble remembering things.
- D. I have lost weight over the past month.
Correct Answer: A
Rationale: Shortness of breath, especially during exertion, is a classic symptom of heart failure due to the heart's inability to pump blood effectively.
BP screenings to detect end-organ damage should be done routinely beginning at what age?
- A. Birth
- B. 3 years
- C. 8 years
- D. 13 years
Correct Answer: B
Rationale: The recommended age to establish a baseline blood pressure in a healthy child is around 3 years.
Management of a patient with an INR of 8.7 from warfarin overdose includes:
- A. Vitamin K
- B. Cryoprecipitate
- C. Fresh frozen plasma
- D. Desmopressin
Correct Answer: A
Rationale: The correct answer is A because vitamin K is the primary treatment for reversing warfarin overdose. The other options (b-e) are less commonly used or not indicated for this situation.
Treatment for congestive heart failure (CHF) in an infant began 3 days ago and has included digoxin and furosemide. The child no longer has retractions, lungs are clear, and HR is 96 beats per minute while sleeping. The nurse is confident that the child has diuresed successfully and has good renal perfusion when the nurse notes the child's urine output is:
- A. 0.5 cc/kg/hr
- B. 1 cc/kg/hr
- C. 30 cc/hr
- D. 1 oz/hr
Correct Answer: B
Rationale: Normal pediatric urine output is approximately 1 cc/kg/hr.
In the treatment of hypothyroidism in children:
- A. Levodopa is the treatment of choice
- B. Levothyroxine should be used
- C. Triiodothyronine is the first line treatment
- D. Carbimazole is indicated
Correct Answer: B
Rationale: Levothyroxine is the treatment of choice for hypothyroidism, as it replaces the deficient thyroid hormone and helps normalize metabolic functions.