Nokea
The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans would be a priority to meet the needs of this father?
- A. Encourage the father to call his wife after work.
- B. Instruct the father about visiting policy and suggest AM visitation.
- C. Adjust visiting hours to meet the new parents' needs.
- D. Present a change of visiting hours to the appropriate hospital committee.
Correct Answer: C
Rationale: Adjusting visiting hours accommodates the father’s evening shift, enabling bonding with his newborn, a priority for family-centered care. Options A and B are less flexible, and option D is a long-term solution, not immediate.
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An 8-year-old girl has a closed transverse fracture of her right ulna.
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
- A. Check the radial pulses bilaterally and compare.
- B. Evaluate the skin temperature and tissue turgor in the area.
- C. Assess sensation of each foot while the girl closes her eyes.
- D. Apply baby powder to decrease skin irritation under the cast.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
- A. What is the most appropriate action for the nurse when administering haloperidol decanoate IM?
- B. Massage the injection site.
- C. Give deep IM in a large muscle mass.
- D. Use a 2 inch 25 gauge needle.
- E. Administer the medication in divided doses.
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.
A client after a bronchoscopy.
The nurse would be MOST concerned if which of the following was observed?
- A. Depressed gag reflex.
- B. Sputum streaked with blood.
- C. Tachypnea.
- D. Complaints of a sore throat.
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.