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A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?
- A. Complete blood count
- B. Lactose tolerance test
- C. Skin allergy testing
- D. Serum immunoglobulin E
Correct Answer: D
Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.
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Which intervention should be included in the long-term plan of care for a client with COPD?
- A. Administer high-flow oxygen during sleep.
- B. Reduce risk factors for infection.
- C. Limit fluid intake to reduce secretions.
- D. Use diaphragmatic breathing to achieve better exhalation.
Correct Answer: D
Rationale: The correct answer is D: 'Use diaphragmatic breathing to achieve better exhalation.' Diaphragmatic breathing is an essential intervention for clients with COPD as it helps improve exhalation and lung function, ultimately reducing symptoms over the long term. Option A is incorrect because high-flow oxygen during sleep is more relevant for clients with conditions like sleep apnea rather than COPD. Option B, 'Reduce risk factors for infection,' is important but not as specific to the long-term management of COPD as diaphragmatic breathing. Option C, 'Limit fluid intake to reduce secretions,' is not a recommended intervention for clients with COPD, as adequate hydration is crucial for maintaining respiratory health.
A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?
- A. Multiple firm, round, freely movable masses.
- B. A slight asymmetry of the breasts.
- C. A fixed nodular mass with dimpling of the skin.
- D. Bloody discharge from the nipple.
Correct Answer: C
Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.
A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?
- A. Administer intravenous insulin.
- B. Start an intravenous fluid bolus.
- C. Obtain a blood glucose level.
- D. Administer an antiemetic.
Correct Answer: B
Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?
- A. Localized warmth
- B. Calf pain
- C. Swelling in the affected leg
- D. Hematuria
Correct Answer: D
Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.
Which documentation indicates that activities to prevent postoperative venous stasis were performed correctly?
- A. Antiembolism stockings on, leg exercises performed hourly.
- B. Antiembolism stockings removed hourly during leg exercises.
- C. Leg exercises not performed due to antiembolism hose.
- D. Client demonstrates ability to move extremities well.
Correct Answer: A
Rationale: The correct answer is A: 'Antiembolism stockings on, leg exercises performed hourly.' This documentation indicates the correct performance of activities to prevent postoperative venous stasis, as both components are crucial for prevention. Choice B is incorrect because removing stockings hourly is not recommended. Choice C is incorrect as leg exercises should be performed despite wearing antiembolism stockings. Choice D is incorrect as demonstrating the ability to move extremities well does not specifically address the prevention of venous stasis.