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A nurse is assisting with care for an adolescent client who has asthma and a new prescription for albuterol by metered-dose inhaler. Which of the following statements by the client indicates that they might be experiencing an adverse effect of albuterol?
- A. My body feels relaxed after taking my medication.
- B. My heart feels like it's fluttering after taking my medication.
- C. I experience forgetfulness after taking my medication.
- D. I become constipated after taking my medication.
Correct Answer: B
Rationale: Heart fluttering indicates palpitations, a known albuterol side effect. Relaxation is desired, while forgetfulness and constipation are not typical.
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A nurse is reinforcing discharge teaching about preventing infections with the parent of a child who is receiving chemotherapy and has a platelet count of 100,000/mm3. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will take my child's rectal temperature daily to ensure the most accurate reading.
- B. I will make sure my child receives the MMR vaccine by the end of the week.
- C. I will take my child to the park to ride her new bike.
- D. I will inspect the inside of my child's mouth for sores every day.
Correct Answer: D
Rationale: Inspecting the mouth for sores detects mucositis early, reducing infection risk. Rectal temperatures, live vaccines like MMR, and park visits increase infection risk during chemotherapy.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
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 reinforcing teaching about injury prevention with the parents of a toddler. Which of the following instructions should the nurse include in the teaching?
- A. Install window guards on windows.
- B. Place scatter rugs over hardwood floors.
- C. Keep doors locked.
- D. Supervise at playgrounds.
- E. Turn pot handles toward the front of the stove.
Correct Answer: A,C,D
Rationale: Window guards prevent falls, locked doors limit access to hazards, and supervision at playgrounds ensures safety. Scatter rugs increase tripping risks, and pot handles should face inward to prevent burns.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.