Nokea
A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI?
- A. I should look for more frequent urination and strong-smelling urine.
- B. My child would have tea-colored urine and puffiness around the eyes.
- C. I should observe for episodes of nausea and less frequent urination.
- D. My child would have pale-colored urine and abdominal tenderness and pain.
Correct Answer: A
Rationale: Frequent urination and strong-smelling urine are classic signs of a UTI.
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Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
Which is the recommended treatment for moderate to severe lead poisoning?
- A. IV fluids
- B. Antiemetics
- C. Heavy metal antagonist
- D. Antibiotics
Correct Answer: C
Rationale: The heavy metal antagonist, edetate calcium disodium, is frequently the drug of choice for the removal of the lead toxin from the body. Chelating agents inactivate the toxicity of the lead and cause excretion through the urine. IV fluids, antiemetics, and antibiotics do not address the core issue of removing lead from the body.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.