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A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Absence of hypoglycemic episodes
- D. Cessation of nocturnal enuresis
Correct Answer: D
Rationale: The correct answer is D: Cessation of nocturnal enuresis. Desmopressin is a medication used to treat diabetes insipidus by decreasing urine output. Nocturnal enuresis is a common symptom of diabetes insipidus due to excessive urine production at night. Therefore, the cessation of nocturnal enuresis indicates that the medication is effectively reducing urine output in the child. Choices A, B, and C are unrelated to the effectiveness of desmopressin in treating diabetes insipidus. Choice A, heart rate of 140/min, is not a specific indicator of desmopressin effectiveness. Choice B, capillary refill of 3 seconds, is a measure of peripheral perfusion and not directly related to diabetes insipidus. Choice C, absence of hypoglycemic episodes, is more relevant to diabetes mellitus and not diabetes insipidus.
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A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.
A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.
A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.
A nurse is caring for a child who has impetigo contagiosa and developed in the hospital. Which of the following actions should the nurse take?
- A. Report the infection to the state health department.
- B. Administer penicillin G, IV.
- C. Initiate contact isolation precautions.
- D. Apply a topical antifungal cream.
Correct Answer: C
Rationale: Correct Answer: C - Initiate contact isolation precautions.
Rationale: Impetigo contagiosa is highly contagious, caused by bacteria, not fungi. Contact isolation helps prevent the spread of infection. Reporting to the state health department is important, but immediate isolation is crucial. Administering penicillin G is not the first-line treatment for impetigo. Applying an antifungal cream is incorrect as impetigo is caused by bacteria, not fungi.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Ensure that area rugs have rubber backs.
- C. Mark the edges of the doorway to the house with tape.
- D. Place a throw rug over electrical cords.
Correct Answer: B
Rationale: The correct answer is B: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, especially for an older adult recovering from knee replacement surgery. Rubber-backed rugs provide traction and stability, reducing the risk of accidents. Encouraging the client to avoid wearing shoes at home (A) may increase the risk of slipping on smooth surfaces. Marking the edges of the doorway with tape (C) may not be effective and could create a tripping hazard. Placing a throw rug over electrical cords (D) is unsafe as it can cause the older adult to trip.