Nokea
A school nurse is assessing a child who has frequent absences from school due to asthma. Which of the following is the priority nursing action?
- A. Teaching the child how to use an inhaler
- B. Assessing the child's asthma management plan
- C. Discussing the importance of school attendance with the parents
- D. Referring the child to a pulmonologist
Correct Answer: B
Rationale: The correct answer is to assess the child's asthma management plan. This is the priority action as it allows the nurse to evaluate the current treatment regimen, identify any gaps or areas for improvement, and ensure that the plan is being effectively implemented. Teaching the child how to use an inhaler (Choice A) may be important but should come after assessing the management plan. Discussing the importance of school attendance with the parents (Choice C) is secondary to ensuring proper asthma management. Referring the child to a pulmonologist (Choice D) may be necessary but is not the priority at this stage; first, the nurse needs to evaluate the current plan in place.
You may also like to solve these questions
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
- A. Non-intention tremors and urgency with voiding
- B. Echolalia and a shuffling gait
- C. Muscle spasm and a bent-over posture
- D. Intention tremor and jerky movement of the elbows
Correct Answer: B
Rationale: The correct answer is B. Echolalia (repeating others' words) and a shuffling gait are common symptoms of Parkinson's disease. These symptoms result from the degeneration of the basal ganglia in the brain that controls movement and speech. Choice A is incorrect because non-intention tremors are not typically associated with Parkinson's disease. Choice C is incorrect as muscle spasm and a bent-over posture are not classic manifestations of Parkinson's disease. Choice D is incorrect since intention tremors and jerky movement of the elbows are not characteristic of Parkinson's disease.
What is the FIRST STEP for thermal protection of a newborn?
- A. Drying the baby thoroughly immediately after birth
- B. Covering the baby with a clean, dry cloth after the cord has been cut
- C. Drying the baby thoroughly after the cord has been cut
- D. Covering the baby with a clean, dry cloth immediately after birth
Correct Answer: A
Rationale: The correct first step for thermal protection of a newborn is to dry the baby thoroughly immediately after birth. This helps prevent heat loss and is crucial in maintaining the baby's body temperature. Choice B, covering the baby with a clean, dry cloth after the cord has been cut, is not the initial step as drying the baby comes first. Choice C, drying the baby thoroughly after the cord has been cut, is also not the first step. Choice D, covering the baby with a clean, dry cloth immediately after birth, is not as effective as drying the baby to prevent heat loss.
For Barangay Mabulaklak, you intend to conduct health education sessions for a group of mothers. Which of the following topics for discussion will be given least priority:
- A. proper selection and preparation of food
- B. handwashing before preparing food
- C. cutting children's fingernails short
- D. overcrowding and its effect
Correct Answer: D
Rationale: The correct answer is D - 'overcrowding and its effect.' While overcrowding is an important topic, it will be given least priority compared to the other choices when conducting health education sessions for a group of mothers. Proper selection and preparation of food (Choice A) is crucial for ensuring adequate nutrition, handwashing before preparing food (Choice B) is essential for preventing foodborne illnesses, and cutting children's fingernails short (Choice C) is important for maintaining good hygiene. Overcrowding, although significant in the context of public health, might be considered less immediately relevant for a group of mothers in a health education session focused on more direct and practical aspects of family health and hygiene.
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by
- A. Inserting a fenestrated catheter with a whistle tip without suction
- B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
- C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
- D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter
Correct Answer: C
Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.
A client with a history of hypertension is receiving enalapril (Vasotec). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia as a side effect. ACE inhibitors can cause potassium retention by inhibiting aldosterone secretion, which may result in elevated potassium levels. Hypoglycemia (choice B) is not typically associated with enalapril use. Hypercalcemia (choice C) is also not a common side effect of enalapril. Hypokalemia (choice D) is the opposite of what is expected with enalapril, as it tends to cause potassium retention.