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A nurse is performing education for the guardians of an HIV positive teen. Which statement indicates the need for further teaching?
- A. It is important for her to have normal growth and development.
- B. Adherence to antiretroviral therapy is needed.
- C. We will need to inform the school about her infection.
- D. She should get her annual flu shot at the doctor's office.
Correct Answer: C
Rationale: The correct answer is C. It is not necessary to inform the school about the teen's HIV infection due to confidentiality laws protecting the teen's privacy. Revealing this information could lead to stigma and discrimination. The other statements are all important for the teen's health and well-being. A: Normal growth and development are crucial for overall health. B: Adherence to antiretroviral therapy is necessary to manage the HIV infection. D: Annual flu shots are recommended to prevent complications.
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The nurse is providing education to parents of a toddler that will receive an iron supplement to treat iron deficiency anaemia. Which statement indicates the parents need further teaching?
- A. It's important to rinse my baby's mouth out with water immediately after giving her the iron
- B. We need to store the iron in a safe place because an accidental overdose can be toxic to the baby
- C. If we notice dark green stools, we should immediately notify the doctor.
- D. A good way to prevent iron deficiency anaemia is to limit the baby's milk consumption to 32 ounces per day.
Correct Answer: C
Rationale: The correct answer is C. If parents notice dark green stools after giving iron supplements, it is actually a common and harmless side effect due to the iron's color. They do not need to immediately notify the doctor unless there are other concerning symptoms. Rinsing the baby's mouth after giving iron (A) is important to prevent staining. Storing iron safely (B) is crucial to prevent accidental ingestion. Limiting milk consumption (D) is recommended as excessive milk can hinder iron absorption.
A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include?
- A. Place tongue on the mouthpiece of the meter.
- B. Maintain a semi-Fowler's position during testing.
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D: Blow into the meter as hard and quickly as possible. This instruction is correct because when using a peak expiratory flow meter, the individual needs to blow out as forcefully as possible to get an accurate reading of their peak expiratory flow rate. This helps in assessing the severity of asthma symptoms and monitoring the effectiveness of treatment.
A: Placing the tongue on the mouthpiece is incorrect as it may interfere with the airflow and affect the accuracy of the reading.
B: Maintaining a semi-Fowler's position is not necessary for using a peak flow meter.
C: Recording the average of the readings is not typically done with peak flow meters as the focus is on the individual's peak expiratory flow rate.
E, F, G: No other choices were provided.
In summary, blowing into the meter as hard and quickly as possible is the correct instruction for using a peak expiratory flow meter, as it ensures an accurate measurement of peak expir
Which is the most definitive diagnosis of leukemia?
- A. A detailed history that includes bone pain and recurrent infections
- B. A lumbar puncture to ascertain if leukemic cells are in the cerebral spinal fluid
- C. A CBC with differential to check the morphology of all the blood cells
- D. A bone marrow biopsy will show an infiltrate of blast cells
Correct Answer: D
Rationale: The correct answer is D: A bone marrow biopsy will show an infiltrate of blast cells. A bone marrow biopsy is the gold standard for diagnosing leukemia as it provides direct visualization of the bone marrow cells. In leukemia, there is an abnormal proliferation of immature cells called blast cells. Therefore, the presence of blast cells in the bone marrow biopsy confirms the diagnosis.
A: A detailed history may provide valuable information, but it is not definitive for diagnosing leukemia.
B: A lumbar puncture is more relevant for diagnosing central nervous system involvement in leukemia, not for confirming the diagnosis itself.
C: A CBC with differential can show abnormalities in blood cell counts, but it does not provide direct visualization of blast cells in the bone marrow.
E, F, G: No additional options provided.
In summary, the most definitive diagnosis of leukemia is confirmed through a bone marrow biopsy, which directly shows the presence of blast cells, distinguishing it from the other choices.
Fentanyl 30mcg IV is ordered. The vial contains 0.05mg/ml. How many ml should the nurse administer?
- A. 0.3 ml
- B. 3 ml
- C. 0.06 ml
- D. 0.6 ml
Correct Answer: D
Rationale: To calculate the amount of Fentanyl to administer, first convert 30mcg to mg by dividing by 1000 (30mcg = 0.03mg). Then, divide the dose by the concentration of the vial (0.03mg ÷ 0.05mg/ml = 0.6ml). The correct answer is D (0.6ml). Choice A (0.3ml) is incorrect because it doesn't account for the correct dosage calculation. Choice B (3ml) is incorrect as it is too high, leading to potential overdose. Choice C (0.06ml) is incorrect as it miscalculates the dosage based on the vial concentration.
Solumedrol 1.5mg/kg is ordered for a child weighing 74.8 pounds. Solumedrol is available as 125mg/2ml. How many ml must the nurse administer?
- A. 0.62ml
- B. 0.062ml
- C. 0.82ml
- D. 0.082ml
Correct Answer: C
Rationale: To calculate the dose of Solumedrol, first convert the child's weight to kg: 74.8 lbs / 2.2 = 34 kg. Then, calculate the dose: 1.5 mg/kg * 34 kg = 51 mg. Next, determine how many ml is needed: 51 mg / 125 mg/ml = 0.408 ml, which is rounded up to 0.82 ml. Choice A is incorrect because it is too low. Choice B is incorrect as it is much lower than the calculated dose. Choice D is incorrect as it is also too low.