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A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula.
- B. A school-age child who has diabetes mellitus and requires blood glucose monitoring.
- C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
- D. A toddler who has both arms in casts and needs to be fed his breakfast.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause respiratory distress. Assessing the oxygenation status is a priority to ensure the infant is receiving adequate oxygenation. This can prevent potential complications such as respiratory failure. The other clients have important needs but do not have immediate life-threatening conditions requiring urgent assessment. The school-age child with diabetes requires monitoring but can wait a little longer. The adolescent in sickle cell crisis ready for discharge instructions can be assessed after ensuring the infant's immediate needs are addressed. The toddler with both arms in casts needing feeding can also wait since feeding can be done after the infant's urgent assessment.
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A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
- A. Using the palm of the hand, feel for lumps using a circular motion.
- B. Expect some breast dimpling or discharge with age.
- C. Breasts can be examined in the shower with soapy hands.
- D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
Correct Answer: C
Rationale: The correct answer is C: Breasts can be examined in the shower with soapy hands. This instruction is important because warm water and soap help to make the examination more comfortable and easier to detect any abnormalities. By examining the breasts in the shower, the individual can incorporate BSE into their routine without it feeling like a separate task. This method also allows for better coverage and thorough examination of the entire breast tissue.
Choice A is incorrect because using the palm of the hand in a circular motion may not be as effective in detecting lumps compared to using the fingertips. Choice B is incorrect as breast dimpling or discharge are not normal signs of aging, and should be reported to a healthcare provider. Choice D is incorrect as performing BSE at specific times in the menstrual cycle is not necessary.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. Relapse is an indication that you are not taking your medications properly.
- B. You should keep your provider’s and therapist’s number with you.
- C. Taking an additional dose of medication is appropriate as soon as signs of relapse appear.
- D. You should be aware that excessive sleeping is an early sign of relapse.
Correct Answer: B
Rationale: The correct answer is B: "You should keep your provider’s and therapist’s number with you." This is the correct statement because having easy access to contact information for healthcare providers and therapists is crucial in case of a relapse. It allows the client to seek immediate help and support when needed.
Choice A is incorrect because relapse in schizophrenia can occur even with proper medication adherence. Choice C is incorrect as taking additional medication without consulting a healthcare provider can be dangerous. Choice D is incorrect as excessive sleeping may not always be a reliable early sign of relapse.
A nurse in a provider’s office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation?
- A. Low-grade fever
- B. Weight loss
- C. Anorexia
- D. Knuckle deformity
Correct Answer: D
Rationale: The correct answer is D: Knuckle deformity. Knuckle deformity in rheumatoid arthritis is a late manifestation due to prolonged inflammation and joint damage. This occurs after the initial symptoms such as low-grade fever, weight loss, and anorexia. Low-grade fever, weight loss, and anorexia are early systemic manifestations of RA caused by inflammation and metabolic changes. Knuckle deformity indicates advanced joint damage and chronic inflammation. Therefore, it is considered a late manifestation compared to the other options.