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A nurse is educating a parent of a 6-month-old infant about car seat safety. Which statement from the parent indicates a correct understanding of the teaching?,Which statement indicates correct understanding of car seat safety?
- A. Our car seat is an infant model and is anchored in the car.
- B. The car seat is rear-facing in the front passenger seat.
- C. I can fit my hand between the baby and the car seat harness.
- D. Our car seat is front-facing in the back seat.
Correct Answer: A
Rationale: The correct answer is A because anchoring the infant car seat in the car is crucial for safety. This ensures the seat is securely installed and minimizes the risk of injury during a collision. Choice B is incorrect as rear-facing car seats should never be placed in the front passenger seat due to the presence of airbags, which can be dangerous for infants. Choice C is incorrect because the harness should be snug against the infant's body without any slack, and being able to fit a hand between the harness and the baby indicates it is too loose. Choice D is incorrect as infants should be in rear-facing seats until at least 2 years old for optimal safety.
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A nurse is conducting a patient's history and physical examination. Which information should the nurse consider as subjective data? Which information is subjective data?
- A. Petechiae
- B. Nausea
- C. Cyanosis
- D. Fever
Correct Answer: B
Rationale: Subjective data is information provided by the patient based on their feelings, perceptions, or beliefs. Nausea falls under this category as it is a symptom that the patient experiences and reports subjectively. Petechiae, cyanosis, and fever are objective data as they can be observed or measured directly. Petechiae are small red or purple spots on the skin, cyanosis is a bluish discoloration of the skin due to lack of oxygen, and fever is an elevated body temperature, all of which can be confirmed through visual inspection or measurement. Therefore, choice B, nausea, is the correct answer as it relies on the patient's subjective experience.
A nurse is instructing a patient who has been newly prescribed sumatriptan tablets for the treatment of migraine headaches. Which instructions should the nurse include? What instructions should the nurse include for sumatriptan?
- A. Report any eyelid swelling after dosage.
- B. Repeat the dose in 1 hour if the headache persists.
- C. Take the medication daily to prevent headaches.
- D. Thoroughly chew the tablet before swallowing.
Correct Answer: B
Rationale: The correct answer is B: Repeat the dose in 1 hour if the headache persists. Sumatriptan is used to treat acute migraine attacks, and the patient should be instructed to take a second dose if the headache does not improve after the first dose. This is important because it helps ensure adequate relief of symptoms. Choices A and D are incorrect because eyelid swelling is not a common side effect of sumatriptan, and sumatriptan tablets should be swallowed whole without chewing. Choice C is incorrect because sumatriptan is not taken daily for headache prevention; it is used as needed for acute migraine attacks.
A nurse is caring for a patient whose right leg is in Buck's traction. Which interventions should the nurse implement to promote the patient's mobility? Which intervention promotes mobility in Buck's traction?
- A. Perform passive range of motion exercises on the right leg.
- B. Perform isometric exercises on both legs.
- C. Perform active range-of-motion exercises on the left leg.
- D. Log roll the patient every 2 hours.
Correct Answer: C
Rationale: Rationale: Performing active range-of-motion exercises on the left leg promotes mobility in Buck's traction by maintaining muscle strength and joint flexibility, preventing muscle atrophy, and improving circulation. This helps prevent complications and supports eventual rehabilitation. Passive range of motion exercises on the right leg are not recommended as it may cause discomfort. Isometric exercises on both legs may not address the specific immobilization of the right leg. Log rolling every 2 hours is not directly related to promoting mobility in Buck's traction.
A nurse is reviewing the laboratory results of four children. Which value should the nurse report to the provider? Which lab value should the nurse report?
- A. Iron 38 mcg/dL.
- B. RBC 4.9 million/mm.
- C. WBC 10,000 cells/mm.
- D. Lead 2 mcg/dL.
Correct Answer: A
Rationale: The correct answer is A: Iron 38 mcg/dL. The nurse should report this value as it indicates a low iron level, which can lead to anemia in children. Anemia can have serious consequences on growth and development. Choice B is within the normal range for red blood cell count. Choice C is within the normal range for white blood cell count, which may indicate an infection or inflammation. Choice D is within the acceptable range for lead levels, but it is still important to monitor due to potential toxicity. Reporting the low iron level is crucial for early intervention and prevention of complications.
A nurse is preparing to administer Ringer's lactate via continuous IV infusion at a rate of 120 mL/hr. The manual IV tubing's drop factor is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? How many gtt/min for Ringer's lactate infusion?
Correct Answer: 120
Rationale: The correct answer is 120 gtt/min. To calculate the infusion rate in gtt/min, you first convert the hourly rate to minutes by dividing 120 mL/hr by 60 min/hr, which equals 2 mL/min. Then, multiply the mL/min by the drop factor of 60 gtt/mL to get the answer of 120 gtt/min. This ensures the correct amount of Ringer's lactate is delivered per minute. Other choices are incorrect because they do not follow the correct calculation steps or involve incorrect conversions, leading to inaccurate infusion rates.