Nokea
A patient reports on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
- A. Give the antibiotic
- B. Do not give the antibiotic
- C. Give half of the dose
- D. Discontinue the antibiotic
Correct Answer: B
Rationale: In this scenario, the patient reports being "very sick" after taking erythromycin in the past, indicating a history of adverse reaction to the medication. Given this information, it would be most prudent to withhold the erythromycin to prevent a potential adverse reaction or worsening of the patient's condition. It is important for the nurse to always consider the patient's previous experiences and adverse reactions when administering medications to ensure patient safety.
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At what age can most infants sit steadily unsupported?
- A. 4 months
- B. 6 months
- C. 8 months
- D. 10 months
Correct Answer: C
Rationale: Most infants can sit steadily unsupported at around 8 months of age. By this time, they have developed sufficient strength and control in their core muscles to sit up without support. It is important for parents to provide a safe environment for their infants to practice sitting up and to always supervise them during this milestone development.
Which of the ff information should the nurse provide to clients who are prescribed rifampin?
- A. Take medication with meals
- B. Inform that contact lenses, if worn, may
- C. Avoid wearing glasses become colored
- D. Avoid tuna, aged cheese, and red wine
Correct Answer: B
Rationale: Rifampin is a medication known to cause harmless discoloration of bodily fluids, including tears and sweat. This discoloration can also affect contact lenses if worn by the individual taking rifampin. Therefore, it is important for the nurse to inform clients who are prescribed rifampin about this potential side effect to prevent any concerns or misunderstandings. It is advisable for clients to use glasses instead of contact lenses while taking rifampin to avoid this discoloration.
Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.
When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
- A. Depression
- B. Excessive sleepiness
- C. A history of cocaine use
- D. A preoccupation with death
Correct Answer: D
Rationale: A key indicator of high risk for suicide in a severely depressed adolescent is a preoccupation with death. This preoccupation may manifest as talking about death frequently, expressing a desire to die, or showing an interest in activities or media related to death. It is important for healthcare providers to take any mention of suicidal thoughts or intentions seriously and to assess for other risk factors. While depression, excessive sleepiness, and a history of cocaine use may also be concerning in an adolescent's mental health assessment, a preoccupation with death is a more direct indicator of suicidal risk. It is crucial for healthcare providers to address suicidal ideation promptly and to ensure the adolescent receives appropriate mental health support and interventions.
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The first priority when a woman with pelvic inflammatory disease complains of lower abdominal pain is to administer antibiotics as ordered. Pelvic inflammatory disease is often caused by a bacterial infection, and prompt treatment with antibiotics is crucial to prevent complications such as infertility or chronic pelvic pain. Addressing the infection promptly is essential in managing the condition and preventing further spread of the infection. Once antibiotic therapy has been initiated, the nurse can proceed with other interventions such as pain management (C), patient education on STDs (D), and assessing pain level (A).