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Parents of children receiving chemotherapy should be warned that alopecia is a side effect and that:
- A. Children seldom show concern about losing their hair
- B. The hair will come out gradually, and the loss will not be noticeable for some time
- C. It is best for girls to choose a wig similar to their hair style and color before the hair falls out
- D. The parents will soon get used to seeing their children without hair, and it will no longer bother them
Correct Answer: C
Rationale: Having a wig that looks like a girl's own hair can be a psychological boost to children and is helpful in fostering later adjustments to hair loss.
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The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
- A. A client recovering from a stroke with an oxygen saturation rate of 99%
- B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2°F
- C. A client admitted one hour ago with rales and shortness of breath
- D. A client being prepared for discharge following a right colectomy
Correct Answer: C
Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Two to 4 hours after the last drink
- B. Six to 8 hours after the last drink
- C. Immediately on admission
- D. Twenty-four hours after the last drink
Correct Answer: B
Rationale: This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.
A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:
- A. Apply the ointment to healthy skin
- B. Cover the wound with a dry dressing
- C. Clean the wound before application
- D. Expose the wound to air after application
Correct Answer: C
Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.
The physician has ordered a 24-hour urine collection for a client. Which instruction should the nurse provide?
- A. Discard the first void and then collect all urine for 24 hours.'
- B. Collect all urine in a single container for 24 hours.'
- C. Refrigerate each void separately before combining.'
- D. Collect only the first and last voids of the day.'
Correct Answer: A
Rationale: For a 24-hour urine collection, the first void is discarded, and all subsequent urine is collected for exactly 24 hours to ensure accurate measurement of analytes. A single container is used, refrigeration is advised, but separate voids are not needed.
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL. What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. 1.13 mEq
- C. 2 mEq
- D. 3 mEq
Correct Answer: C
Rationale: 1.33 mEq = 1 mL, then 1.5 mL X = 1.99, or 2 mEq.