Nokea
An infant with Tetralogy of Fallot is discharged with a prescription for Lanoxin elixir. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz of water
Correct Answer: B
Rationale: Using the calibrated dropper ensures accurate dosing of Lanoxin (digoxin) elixir for an infant with Tetralogy of Fallot, critical due to its narrow therapeutic range and cardiac effects. Nipples, spoons, or dilution in bottles risk under- or overdosing. Nurses teach this method to parents, stressing precision to manage heart defects safely, preventing toxicity or inefficacy.
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The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
Myra said 'I saw my dead grandmother here at my bedside a while ago' Budek responded 'Really? That is hard to believe, How do you feel about it?' What technique did Budek used?
- A. Disproving
- B. Disagreeing
- C. Voicing Doubt
- D. Presenting Reality
Correct Answer: C
Rationale: Budek's 'Really? That is hard to believe uses voicing doubt (C), gently questioning Myra's perception (hallucination) while exploring feelings. Disproving (A) or disagreeing (B) outright rejects (e.g., 'That's not true'). Presenting reality (D) corrects (e.g., 'She's not here'). Voicing doubt, per schizophrenia care, balances reality-testing with empathy, making C correct.
Too narrow cuff will cause what change in the Client's BP?
- A. True high reading
- B. True low reading
- C. False high reading
- D. False low reading
Correct Answer: C
Rationale: A narrow cuff e.g., under-sized overcompresses, yielding a false high BP e.g., 140/90 vs. true 120/80. True readings need proper fit; wide cuffs may lower falsely. Nurses select cuffs e.g., per arm size for accuracy, per measurement standards.
Which actions are examples of an RN participating in illness prevention for a client with hypertension?
- A. Teaching lifestyle modifications
- B. Reporting low blood pressure to the health care provider
- C. Administering ordered medication
- D. Performing risk screenings for hypertension
Correct Answer: A
Rationale: Illness prevention in nursing focuses on proactive measures to stop disease development, particularly for conditions like hypertension. Teaching lifestyle modifications, such as diet and exercise, empowers clients to manage blood pressure and reduce risk, aligning with primary prevention's educational emphasis. Performing risk screenings identifies hypertension early, enabling timely intervention before complications arise, another primary prevention strategy. Providing heart-healthy diet literature reinforces these efforts, equipping clients with practical tools for prevention. Reporting low blood pressure or administering medications, while critical interventions, address existing conditions rather than prevent onset, falling under treatment or management. Nurses' preventive role leverages education and screening to foster healthy habits and early detection, significantly impacting chronic disease trajectories like hypertension, where lifestyle plays a pivotal role.
Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?
- A. Empathy
- B. Positive regard
- C. Comfortable sense of self
- D. Self awareness
Correct Answer: B
Rationale: Nurse Aida uses positive regard (B), valuing Roger as a human despite his behavior, a key therapeutic communication ingredient per Rogers. Empathy (A) involves feeling with the client, not just valuing them. Comfortable sense of self (C) is the nurse's confidence, and self-awareness (D) is understanding one's reactions. Positive regard fosters acceptance, crucial for trust and healing, aligning with Aida's stance, making B correct.