Nokea
Priorities to be considered intermediate are:
- A. the nonemergency, non-life-threatening needs of the client.
- B. those tasks that can be delegated to assistive personnel.
- C. those tasks that can be performed at the end of the shift.
- D. those task that can be performed at any time.
Correct Answer: A
Rationale: Priorities designated as intermediate by the nurse are those that are not urgent. They do not affect the client's immediate physiological status.
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Which medication prescriptions should the nurse question? Select all that apply.
- A. Cephalexin for a client with severe allergy to penicillin
- B. Fexofenadine for a client with hives
- C. Ibuprofen for a client with asthma and nasal polyps
- D. Lisinopril for a client with diabetes mellitus
- E. Propranolol for a client with asthma
Correct Answer: A,C,E
Rationale: Cephalexin (A) is contraindicated in penicillin allergy due to cross-reactivity risk. Ibuprofen (C) can trigger bronchospasm in aspirin-exacerbated respiratory disease, common in asthma with nasal polyps. Propranolol (E) is contraindicated in asthma due to beta-blockade causing bronchoconstriction. Fexofenadine (B) is safe for hives, and lisinopril (D) is appropriate for diabetes to protect kidneys.
A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply.
- A. Difficult to awaken
- B. Dry skin
- C. Frequent, loose stools
- D. Hoarse cry
- E. Tachycardia
Correct Answer: A,B,D
Rationale: Hypothyroidism in infants causes lethargy (A), dry skin (B), and hoarse cry (D) due to slowed metabolism. Loose stools (C) and tachycardia (E) are more typical of hyperthyroidism.
An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
- A. There is an obstruction in the pancreatic duct.
- B. There are gallstones in the gallbladder.
- C. Bile is no longer produced by the gallbladder.
- D. There is an obstruction in the common bile duct.
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
- A. Reports of difficulty falling and staying asleep
- B. Expression of persistent suicidal thoughts
- C. Lack of enjoyment in usual pleasures
- D. Reduced senses of taste and smell
Correct Answer: C
Rationale: Lack of enjoyment in usual pleasures. Anhedonia, a common finding in depression, is the lack of enjoyment in usual pleasures.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.