Nokea
The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?
- A. I can leave right after the shot as I didn't have a reaction last time.'
- B. I will be back in a week for my next allergy shot.'
- C. I will let the doctor know if I get any itchy hives tonight.'
- D. It is okay if I have some redness at the injection site tonight.'
Correct Answer: A
Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.
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The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?
- A. Administer oxygen via nasal cannula for client comfort and safety
- B. Clean area with povidone iodine in a circular motion moving outward
- C. Hold the child with the head and knees tucked in and the back rounded out
- D. Monitor and record vital signs every 15 minutes throughout the procedure
Correct Answer: C
Rationale: During a lumbar puncture for an infant, holding the child in a flexed position with head and knees tucked and back rounded ensures proper spinal alignment for safe needle insertion. Oxygen is not routinely needed, cleaning is typically done by the provider, and vital sign monitoring is important but not the primary intervention.
The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.
The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?
- A. I will avoid naps later in the day.'
- B. I will keep the bedroom temperature cool.'
- C. I will read in bed before trying to go to sleep.'
- D. I will try to go to bed and wake up at the same time each day.'
Correct Answer: C
Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.
Which statement, if made by the client, indicates a possible problem?
- A. I have a bowel movement every other day.'
- B. My stools recently are black.'
- C. Sometimes I have to strain when I go to the bathroom.'
- D. I usually have three stools a day.'
Correct Answer: B
Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.
The nurse aus.Concurrent with the above question, the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
- A. Administer an inhaled bronchodilator
- B. Check marked insertion depth of the tube
- C. Request a prescription for a diuretic
- D. Start the client on incentive spirometry
Correct Answer: C
Rationale: Crackles and diminished breath sounds in the lung bases postpartum suggest fluid overload or pulmonary edema, possibly due to prolonged labor or excessive IV fluids. Requesting a diuretic is appropriate to reduce fluid overload. Bronchodilators are for bronchospasm, checking tube depth is irrelevant without an endotracheal tube, and incentive spirometry is less urgent.