Nokea
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain
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A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle
The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
- A. Trust your doctors. They are excellent pediatricians and will know what to look for.
- B. There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.
- C. It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems.
- D. You feel guilty about your son's illness, and that's understandable. You will feel better after you get home.
Correct Answer: C
Rationale: if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response
A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.
An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP?
- A. Administer a cathartic enema to cleanse the bowel.
- B. Obtain information about client allergies.
- C. Instruct the client to be NPO after midnight.
- D. Teach the client that x-rays will be taken at multiple intervals.
Correct Answer: B
Rationale: assessment, clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV