Nokea
Steam inhalation is prescribed for a client. Which of the following safety precautions should the nurse include in the client's instructions?
- A. Use distilled water in the humidifier.
- B. Keep the humidifier filled to the top with water.
- C. Turn the humidifier off when not in use.
- D. Clean the humidifier every 2 weeks.
Correct Answer: C
Rationale: Turning off the humidifier when not in use prevents electrical hazards and bacterial growth. Distilled water is ideal but not critical, overfilling is unnecessary, and cleaning frequency depends on use.
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Which of the following signs should the nurse be aware of on a patient who is taking prednisone?
Melena
- A. Hypoglycemia
- B. Hypekalemia
- C. Low platelet counts
Correct Answer: A
Rationale: Prednisone can cause gastrointestinal irritation, leading to melena, a sign of bleeding.
A 5-month-old infant is admitted to the ER with a temperature of 103.6° and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical sign in bacterial meningitis.
A client asks the nurse about her beta-blockers medication effect to her angina.
What would be the nurse's response?
- A. Decrease cardiac output.
- B. Increase cardiac output.
- C. Decrease cardiac contractility.
- D. Increase cardiac contractility.
Correct Answer: C
Rationale: Beta-blockers decrease heart rate and cardiac contractility, reducing myocardial oxygen demand and relieving angina.
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings would require immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Weight gain of 1 kg since last dialysis.
- C. Bright red blood in the dialysis tubing.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: C
Rationale: Bright red blood in the dialysis tubing indicates a potential access site bleed or tubing disconnection, requiring immediate intervention to prevent blood loss. Mild hypertension (A) and weight gain (B) are common, and a normal potassium level (D) is unremarkable.