Nokea
A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A. An untoward, adverse drug reaction associated with the quinolones is tendon rupture.
- B. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
- C. A 7 year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.
- D. A 7 year-old girl that had a cast on her right ankle is complaining of itching.
Correct Answer: B
Rationale: An untoward, adverse drug reaction associated with the quinolones is tendon rupture. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
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All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
The nurse is demonstrating the use of a fire extinguisher during a fire drill. Place the steps for using a fire extinguisher in the correct order.
- A. Squeeze the handle
- B. Sweep from side to side
- C. Pull the pin
- D. Aim at the base of the fire
Correct Answer: C,D,A,B
Rationale: The PASS technique is: Pull the pin (C), Aim at the base (D), Squeeze the handle (A), Sweep side to side (B).
The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply.
- A. Pad bed side rails.
- B. Install safety bars around the toilet and shower.
- C. Install an elevated toilet seat in the bathroom.
- D. Plan for the client's bed to be in a main floor room.
- E. Use a nonskid bathmat in the bathtub for the client's daily bath.
- F. Remove scatter rugs and secure electrical cords against baseboards.
Correct Answer: B,C,D,F
Rationale: B: Safety bars aid mobility. C: Elevated toilet seat prevents excessive hip flexion. D: Main floor bedroom avoids stairs. F: Removing rugs and cords prevents tripping. A is unnecessary, and E is incorrect as tub baths are avoided post-THR.