Nokea
A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
- A. Scoliosis
- B. Ankylosis
- C. Kyphosis
- D. Lordosis
Correct Answer: A
Rationale: Scoliosis is characterized by an abnormal lateral curvature of the spine.
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A nurse is reinforcing teaching about methylphenidate (Ritalin) with the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
- B. You will need to give your child the medication after meals.
- C. You will need to have your child's blood glucose level checked monthly.
- D. You should not give your child the medication on weekends.
Correct Answer: A
Rationale: Methylphenidate is a stimulant and giving it too late in the day can cause insomnia.
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- A. Lime ice pop
- B. Cranberry juice
- C. Ice cream
- D. Hot tea
Correct Answer: A
Rationale: A lime ice pop is a good option because it is cold soothing and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. Assist with administering a blood transfusion.
- B. Withhold opioids to avoid dependence.
- C. Encourage exercise.
- D. Initiate a 2 L/day fluid restriction.
Correct Answer: A
Rationale: Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.