Nokea
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
- A. The risk of transmission decreases once my child is on zidovudine for 2 weeks
- B. My child will need to double his medications for the next 6 months.
- C. My child will need to repeat his childhood immunizations once he's in remission.
- D. I will ensure that my child is tested for tuberculosis every year.
Correct Answer: D
Rationale: The correct answer is D because regular testing for tuberculosis is crucial for individuals with HIV due to their increased risk of developing tuberculosis. This indicates the parent understands the importance of monitoring for potential complications. Choice A is incorrect because zidovudine does not impact transmission risk. Choice B is incorrect as doubling medications without healthcare provider guidance can be harmful. Choice C is incorrect as childhood immunizations are typically not repeated in remission.
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A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.
A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.
A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Pull the pinna of the infant's ear forward before inserting the probe.
- B. Place the tip of the thermometer under the center of the infant's axilla.
- C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
- D. Insert the oral thermometer in front of the infant's tongue.
Correct Answer: B
Rationale: Correct Answer: B - Place the tip of the thermometer under the center of the infant's axilla.
Rationale: The axillary temperature is a common method for measuring an infant's temperature. Placing the thermometer under the center of the axilla ensures an accurate reading without causing discomfort or harm to the infant.
Incorrect Choices:
A: Pulling the pinna of the infant's ear forward before inserting the probe is not necessary for measuring temperature.
C: Inserting the probe 3.8 cm (1.5 in) into the infant's rectum is invasive and not appropriate for routine temperature measurement.
D: Inserting the oral thermometer in front of the infant's tongue is incorrect as oral thermometers are not suitable for infants due to the risk of choking.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Ensure that area rugs have rubber backs.
- C. Mark the edges of the doorway to the house with tape.
- D. Place a throw rug over electrical cords.
Correct Answer: B
Rationale: The correct answer is B: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, especially for an older adult recovering from knee replacement surgery. Rubber-backed rugs provide traction and stability, reducing the risk of accidents. Encouraging the client to avoid wearing shoes at home (A) may increase the risk of slipping on smooth surfaces. Marking the edges of the doorway with tape (C) may not be effective and could create a tripping hazard. Placing a throw rug over electrical cords (D) is unsafe as it can cause the older adult to trip.