Nokea
A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms would suggest to the nurse that the child has strabismus?
- A. When the child draws, he places his head close to the table.
- B. The child rubs his eyes frequently.
- C. The child closes one eye to see a poster on the wall.
- D. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: visual axes are not parallel so the brain receives two images
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The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
- A. Administer a prescribed antibiotic
- B. Wash her hands for 2 minutes before care
- C. Wear a mask when providing care
- D. Ask the client to cover her mouth when she coughs
Correct Answer: B
Rationale: Hand washing is the most effective measure to prevent postoperative wound infections.
A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which physician prescription would the nurse question?
- A. D5W at 200 mL/hr
- B. Demeclocycline (Declomycin) 150 mg Q6h
- C. Daily weights
- D. Intake and output Q4h
Correct Answer: A
Rationale: D5W at 200 mL/hr is inappropriate for SIADH, as it can worsen hyponatremia by adding free water. The other options are appropriate for monitoring and treating SIADH.
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- A. Mix the drug with normal saline solution
- B. Administer the drug over 4-6 hours
- C. Hydrate with IV fluids 2 hours before the infusion
- D. Premedicate the client - acetaminophen (Tylenol) and diphenhydramine (Benadryl)
Correct Answer: A
Rationale: Amphotericin B should not be mixed with normal saline due to precipitation risk; it requires dextrose solutions. Slow administration, hydration, and premedication are standard to reduce side effects.
The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?
- A. hemoglobin 4.8 g/dL
- B. troponin T 0.04 ng/mL
- C. phosphorus 3.8 mg/dL
- D. bilirubin (total) 0.7 mg/dL
Correct Answer: A
Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.
The nurse is providing instruction to a client's family regarding home safety with thrombocytopenia. Which statement by the client's family indicates a need for further education?
- A. He should use an electric razor for shaving instead of a razor.
- B. We will use soft-bristled toothbrushes or tooth sponges for oral care.
- C. He can no longer take aspirin or aspirin-containing products for a headache.
- D. We should put rugs down on the hardwood floors to prevent his feet from getting cold.
Correct Answer: D
Rationale: Rugs pose a tripping hazard, increasing bleeding risk in thrombocytopenia. Other statements reflect safe practices to minimize bleeding.