Nokea
A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?
- A. Bradycardia.
- B. Tachypnea.
- C. General pallor.
- D. Irritability.
Correct Answer: B
Rationale: increase in the respiratory rate is an early sign of hypoxia, also for tachycardia
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An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
- A. Serum digoxin of 1.2 ng/mL
- B. Serum K+ of 3.0 mEq/L
- C. BUN of 12 mg/dL
- D. Serum Mg of 1.6 mEq/L
Correct Answer: B
Rationale: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.
The nurse is preparing a client environment that will reduce the chance of falls. Which action is appropriate?
- A. Keep the half side rails down on the side the client uses to get out of bed.
- B. Keep the lights down since glare bothers some clients.
- C. Call housekeeping to clean up the spilled water.
- D. Make sure that a path is cleared to assist the client when walking.
Correct Answer: D
Rationale: Clearing a path reduces tripping hazards, a key environmental modification to prevent falls.
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
- A. The child was probably not exposed to it until recently.
- B. Antibodies from the mother are present for the first year of life.
- C. The symptoms do not manifest until the child is no longer breastfeeding.
- D. High fetal hemoglobin levels prevent symptoms for the first year of life.
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.
The nurse is assessing cranial nerve XI. The nurse should:
- A. open a vial of cloves and ask the client to identify the scent.
- B. shine a flashlight in the client's eyes and observe the pupils.
- C. ask the client to shrug his shoulders.
- D. use the Snellen chart and have the client identify letters.
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls neck and shoulder muscles; shoulder shrugging tests its function, unlike scent (I), pupil response (III), or vision (II).
A one-year-old child.
While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?
- A. Take a rectal temperature.
- B. Auscultate the breath sounds.
- C. Auscultate the apical heart rate.
- D. Evaluate motor functions.
Correct Answer: A
Rationale: Strategy: Picture the situation. (1) correct-all invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child (2) should be done before a rectal temperature (3) should be done before a rectal temperature (4) should be done before a rectal temperature