Nokea
A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non-corrosive substance that has no recommended antidote. The nurse should recommend performing gastric lavage with which of the following substances?
- A. Activated charcoal
- B. Osmotic diarrheal agents
- C. Syrup of ipecac
- D. 0.9% sodium chloride
Correct Answer: A
Rationale: Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body. Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements. Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases. 0.9% sodium chloride, or normal saline, is a type of fluid that's often used in medical treatments, but it's not typically used in gastric lavage for poisoning.
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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034.
- B. Bounding pulse.
- C. BP 46/94 mm Hg.
- D. Distended neck veins.
Correct Answer: A
Rationale: A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration. A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse. A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure. Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
- A. Rapid respirations
- B. Diminished reflexes
- C. Acetone breath
- D. Diaphoresis
Correct Answer: D
Rationale: Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis. Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system. Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia. Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system's response to hypoglycemia.
A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit. The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks. Parents report the vomiting is now forceful and projectile ('like a volcano erupting') immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry. The infant has been receiving a cow's milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks. The last weight in the pediatrician's office is 3.54kg (8 lb). No other significant medical or surgical history. What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client's progress?
- A. Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits
- B. Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency
- C. Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency
- D. Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions
Correct Answer: B
Rationale: Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis. Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant's lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant's weight and frequency of vomiting to assess the infant's progress. Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea. However, the symptoms described by the parents do not align with this condition. Milk Protein Allergy in infants is a condition where the infant's immune system reacts negatively to the proteins in cow's milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
Upon finding a school-age child having a seizure, what should be the nurse's first action after lowering the client to the floor?
- A. Turn the client to a lateral position.
- B. Administer an anticonvulsant medication.
- C. Apply oxygen by nasal cannula.
- D. Check the client's oxygen saturation.
Correct Answer: A
Rationale: The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury. Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side. Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side. Checking the client's oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side.
A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?
- A. Shingles
- B. Athlete's foot
- C. Fever blister
- D. Pinworms
Correct Answer: B
Rationale: Shingles, also known as herpes zoster, is a viral infection that causes a painful rash and is caused by the varicella-zoster virus, the same virus that causes chickenpox. Tinea pedis is a foot infection due to a dermatophyte fungus. It is the most common dermatophyte infection and is particularly prevalent in hot, tropical, urban environments. Interdigital involvement is most commonly seen (this presentation is also known as athlete's foot, although some people use the term for any kind of tinea pedis). Fever blister, also known as cold sores, are caused by the herpes simplex virus. They are small, fluid-filled blisters that develop on the lips or around the mouth. Pinworms are a type of parasite that lives in the lower intestine of humans. They are tiny, narrow worms. They are white and less than a half-inch long.