Nokea
A nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. Why do you think they're not eating?
- C. I'm sure it's nothing serious and their appetite will return soon.
- D. They may need a feeding tube.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.
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A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Clasp their hands together in a relaxed position behind their body at their waist.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist prevents glove contamination.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart.
- D. Cleanse the client's finger with an iodine swab.
- E. Apply clean gloves.
Correct Answer: B,E
Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
The client is at risk for developing ___ as evidenced by the client's ___
- A. Infection
- B. WBC count
Correct Answer: A,B
Rationale: A: Chemotherapy lowers immunity, increasing infection risk. B: Decreased WBC count (4,000/mm³) indicates leukopenia.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Grasp the outermost flap of the sterile kit while opening away from the body.
- B. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- C. Open each side flap of the sterile kit individually while pulling to the side.
- D. Prepare a dry work surface above the waist level.
- E. Open the outside cover of the sterile kit and remove the dust cover.
Correct Answer: D,E,A,C,B
Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.