Nokea
For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
- A. Institute seizure precautions
- B. Weigh the child twice per shift
- C. Encourage the child to eat protein-rich foods
- D. Relieve boredom through physical activity
Correct Answer: A
Rationale: Institute seizure precautions. The severity of AGN is unpredictable, and complications like seizures may occur due to hypertension.
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A 9-month old is seen in the well child clinic. During the nursing assessment, the mother asks, 'Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying dada.' The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age:
- A. 1 month
- B. 2 months
- C. 4 months
- D. 8 months
Correct Answer: D
Rationale: Infants typically make cooing or babbling sounds by 6-8 months. Lack of sounds at 9 months warrants evaluation.
The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.
The nurse enters the room of a woman who had a vaginal hysterectomy three days ago and finds her crying. What is the best initial approach for the nurse?
- A. Ask her what seems to be troubling her
- B. Reassure her that feeling depressed is normal after this type of surgery
- C. Tell her that the nurse will ask the doctor to order hormones for her
- D. Leave the room so she can work out her feelings
Correct Answer: A
Rationale: Asking about her concerns opens therapeutic communication, addressing her emotional needs directly and empathetically.
The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.