Nokea
A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse?
- A. Acetaminophen being given every 4 hours for fever
- B. Bismuth subsalicylate being used for nausea
- C. Ibuprofen being given every 6 hours for body aches
- D. Popsicles and gelatin desserts being used for hydration
Correct Answer: B
Rationale: Bismuth subsalicylate is contraindicated in children with viral infections due to Reye syndrome risk, requiring intervention. Other actions are appropriate.
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A client is scheduled for a percutaneous kidney biopsy at 1000. The practical nurse reviews the client's vital signs and most current serum laboratory results at 0600. Which of the following client findings is most important to report to the registered nurse?
- A. hemoglobin of 9.8 g/dL (98 g/L)
- B. blood pressure of 180/100 mm Hg
- C. creatinine of 2.0 mg/dL (177 µmol/L)
- D. platelet count of 120,000/mm³ (120 × 10â¹/L)
Correct Answer: B
Rationale: Severe hypertension (180/100 mm Hg) increases bleeding risk during a kidney biopsy, requiring immediate reporting. Other findings are concerning but less urgent.
The nurse is working to prevent falls in a restraint-free environment. Which of the following is inappropriate for the nurse to delegate to assistive personnel?
- A. Making sure the bed is in low position
- B. Making sure the bedside table is within reach of the client
- C. Assessing the safety needs of the client
- D. Monitoring client behavior for potential falls
Correct Answer: C
Rationale: Assessing safety needs requires nursing judgment, inappropriate for delegation to assistive personnel, unlike routine tasks like bed positioning.
A client with osteoporosis has been advised to increase the amount of calcium in her diet. Which food provides the most calcium?
- A. An 8-ounce glass of milk
- B. An ounce of cheddar cheese
- C. A half cup of raw broccoli
- D. A 4-ounce salmon croquet
Correct Answer: A
Rationale: An 8-ounce glass of milk provides ~300 mg of calcium, more than cheese (B, ~200 mg/oz), broccoli (C, ~20 mg/half cup), or salmon (D, ~180 mg/4 oz).
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate effective teaching?
- A. I should take the medication immediately before bedtime.
- B. I should remain in an upright position for 30 minutes after taking the medication.
- C. The medication is more effective if I take it with milk or dairy products.
- D. If I skip a dose, I can take two tablets the next time.
Correct Answer: B
Rationale: This is required to prevent esophageal problems. The medication should be taken in the morning before food or other medications with water, making answers A and C incorrect choices. It should also be taken as ordered, which makes answer D incorrect.
The nurse is caring for a client who had a colostomy two days ago. Which comment the client makes indicates a readiness to learn about caring for the colostomy?
- A. How long will I have to have this thing on my body?'
- B. What is that bag for?'
- C. Did the doctor really do a colostomy?'
- D. Why did this have to happen to me?'
Correct Answer: B
Rationale: Asking about the bag's purpose shows curiosity and readiness to learn about colostomy care. Other comments reflect denial, frustration, or lack of engagement with care.