Nokea
An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
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The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.
A withdrawn, depressed client sits in the day room but refuses to participate in scheduled group activities. When implementing a plan of care the nurse should:
- A. Plan activity that will allow the client to interact with a staff member.
- B. Tell the client that participation in group activities is expected.
- C. Allow the client to select an activity that he can enjoy doing alone.
- D. Ask the client to prepare a list of activities or hobbies he enjoys.
Correct Answer: A
Rationale: One-on-one interaction with a staff member encourages engagement without overwhelming a depressed client. Mandating participation may increase withdrawal. Solitary activities (C, D) do not address social isolation.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler twice a day.
- C. I should report a sore throat to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using fluticasone as a rescue inhaler is incorrect, as it is a corticosteroid for maintenance therapy, not acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, twice-daily use is standard, and sore throat may indicate infection.