Nokea
A nurse in a provider's office is collecting data from an adolescent who has juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6 months. Which of the following client statements should the nurse report to the provider?
- A. I have morning stiffness in my joints.
- B. I have been taking a multivitamin that contains iron.
- C. I noticed some blood in my stool this morning.
- D. I skipped taking my ibuprofen last week after I went swimming.
Correct Answer: C
Rationale: Blood in stool suggests possible GI bleeding from long-term ibuprofen use, requiring urgent reporting. Stiffness is expected, vitamins are benign, and a single missed dose is less critical.
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A nurse is caring for a 4-year-old child who has pneumonia due to varicella zoster. The parent asks the nurse what types of activities are available for the child. Which of the following play activities should the nurse recommend?
- A. Watching cartoons in the unit activity room with peers
- B. Pulling a wagon of stuffed animals in the hallway
- C. Writing a short letter to send to a friend
- D. Playing an alphabet flash card game with the parent
Correct Answer: D
Rationale: Alphabet flashcards are safe, low-exertion, and avoid infection spread. Cartoons with peers, wagon pulling, or writing are riskier or too demanding.
A nurse is caring for a 13-month-old toddler who has a prescription for a urinary catheter. Which of the following urinary catheters should the nurse use?
- A. 5 French
- B. 12 French
- C. 10 French
- D. 14 French
Correct Answer: A
Rationale: A 5 French catheter is appropriate for a toddler to minimize urethral trauma. Larger sizes (10, 12, 14 French) risk discomfort or injury.
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
A nurse is reinforcing car seat safety instructions with the parents of a 15-month-old toddler. Which of the following statements by the parents indicates an understanding of the teaching?
- A. I should place my child in a forward-facing car seat to ensure safety.
- B. I should place my child in the front seat in a rear-facing car seat.
- C. I should continue to use a booster seat until my child is 5 years old.
- D. I should place my child in a rear-facing car seat until age 2.
Correct Answer: D
Rationale: Rear-facing car seats until age 2 protect the child's head, neck, and spine. Forward-facing too early, front-seat placement, or premature booster use increase injury risk.
A nurse is caring for an adolescent client who has a terminal illness. Which of the following statements should the nurse make to the parent?
- A. I will administer pain medication on a schedule.
- B. I will limit visits from siblings who are under the age of 18.
- C. You should go home when your child needs to rest.
- D. You should allow your child to die at home.
Correct Answer: A
Rationale: Scheduled pain medication ensures comfort. Limiting sibling visits, dictating parental presence, or suggesting home death disregard family preferences and needs.