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A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?
- A. I'll give him acetaminophen for the pain.
- B. I'll discard his toothbrush and buy another.
- C. I'll continue to encourage him to drink lots of fluids.
- D. I'll take his temperature every 4 hours.
Correct Answer: B
Rationale: Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.
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A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Lie prone on the examination table.
- C. Touch your chin to your chest, and then look up at the ceiling.
- D. Turn to the side, and remain in a relaxed position.
Correct Answer: A
Rationale: This position known as the Adam's forward bend test is commonly used to screen for scoliosis.
A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Diarrhea
- C. Positive Chvostek's sign
- D. Muscle hypotonicity
Correct Answer: D
Rationale: Hypercalcemia can lead to muscle weakness and hypotonicity due to its effects on nerve and muscle function.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Keep the client's leg in a dependent position.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Discourage the client from ambulating.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.