Nokea
A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
- A. Serum potassium
- B. Protein intake
- C. Lactose tolerance
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.
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A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?
- A. Allow the child to stay home when the child seems anxious
- B. Call the teacher to get the child’s schoolwork to do at home
- C. Have the child attend school, starting with a few hours a day
- D. Sit with the child in the classroom whenever possible
Correct Answer: C
Rationale: Gradual exposure to school, starting with partial attendance (C), helps desensitize the child to separation anxiety. Staying home (A) reinforces avoidance, schoolwork at home (B) delays reintegration, and parental presence (D) hinders independence.
A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action?
- A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room
- B. Removes the urine specimen cup from the room in a sealed, leak-proof bag
- C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen
- D. Uses an alcohol-based hand antiseptic after removing gloves
Correct Answer: A
Rationale: Chlorhexidine (A) is not standard for stethoscope cleaning in contact precautions; alcohol or approved disinfectants are used to prevent MRSA transmission. Sealed bags for specimens (B), scrubbing the port (C), and hand hygiene (D) are correct actions to maintain infection control.
The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
Spinal headaches are a common occurrence following spinal anesthesia. Which of the following nursing interventions can help prevent a spinal headache?
- A. Placing the client in a quiet room.
- B. Significantly increasing the client's fluid intake.
- C. Administering PRN pain medication.
- D. Raising the head of the bed to $45^{\circ}$.
Correct Answer: B
Rationale: Increasing fluid intake helps maintain cerebrospinal fluid pressure, reducing the risk of spinal headaches post-spinal anesthesia.
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.