Nokea
A young child is placed on droplet precautions. The nurse is caring for which of the following clients?
- A. A child with cystic fibrosis.
- B. A child with tonsillitis.
- C. A child with bronchitis.
- D. A child with pertussis.
Correct Answer: D
Rationale: droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors
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The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client?
- A. Place a clock at the bedside.
- B. Restrict visitors so that the client is alone during the evening.
- C. Tell the client how to call for help if needed.
- D. Postpone explanation of further tests that the client will need.
Correct Answer: C
Rationale: elderly client who feels isolated and unable to obtain help if needed cannot rest properly
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
- A. Remove the scab.
- B. Apply a wet cloth to the lesion.
- C. Notify the child's parents.
- D. Contact the health department.
Correct Answer: C
Rationale: describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician
A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST?
- A. Observe the client for eight hours to collect additional data.
- B. Perform a complete physical assessment.
- C. Collect a urine specimen for a drug screen.
- D. Encourage the client to talk about whatever is bothering him.
Correct Answer: B
Rationale: best way to identify possible physical complications of alcohol dependence is through a complete physical assessment