Nokea
A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response?
- A. I know how you feel, but the medication will make your child feel better.'
- B. I can't let you do this without calling your physician first.'
- C. Can you tell me why you want to take your child home now?'
- D. I can imagine how hard this is for you, but it's not what's best for the child.'
Correct Answer: C
Rationale: Asking the mother to explain her reasons encourages open communication and helps the nurse understand her concerns, facilitating appropriate support or intervention.
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The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
- A. 5 to 10 mL
- B. 10 to 20 mL
- C. 30 to 90 mL
- D. 75 to 100 mL
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
- A. External.
- B. Cyanosis.
- C. Dyspnea.
- D. Weight loss.
Correct Answer: C
Rationale: Dyspnea indicates inadequate oxygenation, suggesting the activity level may be too strenuous for the client's cardiac capacity post-myocardial infarction.
Place the following steps for mixing NPH and regular insulin in the proper sequential order from # 1 to # 6 below. #1 - Prep the top of the shorter acting insulin with an alcohol swab #2 - Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe. #3 - Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe. #4 - Prep the top of the longer acting insulin vial with an alcohol swab. #5 - Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. #6 - Withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.
- A. 1,5,4,2,3,6
- B. 4,3,2,6, 1,5
- C. 4,2,5,3, 1,6
- D. 1,5,3,6,4,2
Correct Answer: A
Rationale: The correct sequence is: 1) Prep short-acting insulin vial, 2) Inject air into short-acting vial, 3) Withdraw short-acting insulin, 4) Prep long-acting insulin vial, 5) Inject air into long-acting vial, 6) Withdraw long-acting insulin to avoid contamination.
When performing chest percussion on a child, which of the following techniques should the nurse use?
- A. Firmly but gently striking the chest wall to make a popping sound.
- B. Gently striking the chest wall to make a slapping sound.
- C. Percussing over an area from the umbilicus to the clavicle.
- D. Placing a blanket between the nurse's hand and the child's chest.
Correct Answer: A
Rationale: Chest percussion involves firmly but gently striking the chest to produce a popping sound, mobilizing secretions without causing harm.
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.