Nokea
A client's diagnosis of cystic fibrosis was made 13 years ago, and he has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which nursing actions are most important initially?
- A. Placing the client on bed rest and ordering a blood gas analysis.
- B. Ordering a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules.
- C. Applying an oximeter and initiating respiratory therapy.
- D. Inserting an I.V. line and initiating antibiotic therapy.
Correct Answer: C
Rationale: Applying an oximeter to assess oxygen saturation and initiating respiratory therapy are critical initial actions to address labored respirations and support respiratory function in a cystic fibrosis patient with acute symptoms.
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The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse's most important responsibility during the procedure is to:
- A. Administer the topical anesthetic.
- B. Keep the parents informed.
- C. Monitor the client.
- D. Record the procedure.
Correct Answer: C
Rationale: Monitoring the child during conscious sedation ensures safety, detecting respiratory or cardiovascular changes promptly.
A child with a nut allergy is admitted with a severe reaction for the third time in three months. The parent says, 'I am having trouble with the food labels.' The nurse should first:
- A. Assess the parent's ability to read.
- B. Refer the client to the dietician.
- C. Notify the primary care provider.
- D. Obtain a social service consult.
Correct Answer: B
Rationale: A dietician can provide expert guidance on reading labels to avoid allergens. Reading assessment, provider notification, or social services may follow but are not the priority.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
- A. Explain that completing a teaching checklist is required by the hospital.
- B. Help the client find information on the Internet.
- C. Provide the client with written information instead.
- D. Explain that information found on the Internet cannot be trusted.
Correct Answer: B
Rationale: Assisting with finding reliable online information respects the adolescent's autonomy.
The mother of a 6-month-old states that she started her infant on 2% milk. The nurse should first ask the mother:
- A. Do you think your baby will be fine with this milk?
- B. Is it possible for you to switch your baby to whole milk?
- C. Can you tell me more about the reason you switched your baby to 2% milk?
- D. You cannot switch to 2% milk right now. Did your pediatrician tell you to do this?
Correct Answer: C
Rationale: Understanding the reason for the switch helps address misconceptions and provide education.
A 12-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety procedures, the nurse should ask the client to:
- A. Point to the area of the fracture.
- B. Mark the location of the fracture with an 'x' and sign his name.
- C. Confirm with his parents that they have signed the operative permit.
- D. State the surgery risks as understood from the surgeon.
Correct Answer: B
Rationale: Marking the surgical site with an 'x' and signing is a standard safety procedure to confirm the correct site for surgery.