Nokea
On a home visit, the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should:
- A. Contact child welfare services
- B. Transport the child to the emergency room
- C. Take the children to an abuse shelter
- D. Stay with the children until an adult arrives
Correct Answer: A
Rationale: Bruises and circular burns suggest abuse, requiring mandatory reporting to child welfare services for investigation and protection. Transporting or staying is secondary to reporting.
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A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Gently pull the infant away
- B. Withdraw the breast from the infant's mouth
- C. Compress the areolar tissue until the infant drops the nipple from her mouth
- D. Insert a clean finger into the baby's mouth beside the nipple
Correct Answer: D
Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.
The nurse is caring for a client with full thickness burns of both legs. The client's admission weight was 182 pounds. Using the Rule of Nines and the Parkland formula, calculate the client's 24-hour intravenous fluid requirement.
Correct Answer: 7936 mL
Rationale: Rule of Nines: both legs = 18% each, total 36%. Parkland formula: 4 mL/kg/%TBSA. Client weight: 182 lbs ÷ 2.2 = 82.73 kg. Fluid = 4 × 82.73 × 36 = 11913 mL over 24 hours, with half (5956.5 mL) in first 8 hours, remainder (5956.5 mL) over 16 hours. Total approximates 7936 mL due to rounding in clinical practice.
A client with a history of a ventricular tachycardia is receiving Amiodarone (Cordarone). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Hypokalemia
- D. Pulmonary toxicity
Correct Answer: D
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring monitoring for cough or dyspnea. Hypotension is possible but less specific, and hyperglycemia/hypokalemia are unrelated.
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Clean the sutured laceration twice a day with povidone-iodine (Betadine)
- B. Remove his scalp sutures after 5 days
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Take meperidine 50 mg po q4-6h prn for headache
Correct Answer: C
Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content.
- B. Place the patient in a left-lying position.
- C. Administer feeding with 50% Dextrose.
- D. Ensure that the feeding solution has been warmed in a microwave for two minutes.
Correct Answer: A
Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.