Nokea
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.
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Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.
Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
Which of the following actions should the nurse take first?
- A. Ask the client if he is considering harming himself.
- B. Encourage the client to attend a group therapy session.
- C. Administer an antidepressant to the client.
- D. Assist the client in completing his ADLs.
Correct Answer: A
Rationale: The correct answer is A. Asking the client if he is considering harming himself should be the first action because it assesses the client's immediate safety. This step is crucial in identifying any potential suicidal ideation and implementing appropriate interventions to ensure the client's well-being. Encouraging group therapy (B), administering medication (C), and assisting with ADLs (D) are important interventions but should come after addressing the client's safety concerns. It is essential to prioritize actions that address the most critical needs first to provide effective and timely care.
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.