Nokea
The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?
- A. When the course of antibiotics is complete
- B. When a negative CNS culture is obtained
- C. When the antibiotics have been initiated for 24 hours
- D. When the child has no symptoms of the disease
Correct Answer: C
Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.
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A client with a new colostomy is concerned about odor. What is the best advice the nurse can provide?
- A. Avoid high-fiber foods
- B. Use an odor-proof pouch
- C. Decrease fluid intake
- D. Increase dairy products in the diet
Correct Answer: B
Rationale: The best advice the nurse can provide to a client concerned about odor from a new colostomy is to use an odor-proof pouch. This option helps control odors effectively by containing and masking any unpleasant smells. Avoiding high-fiber foods (Choice A) is not the best advice as fiber is essential for bowel health, and decreasing fluid intake (Choice C) can lead to dehydration and other complications. Increasing dairy products in the diet (Choice D) is not directly related to controlling odors from a colostomy.
An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.
- A. Normal Saline
- B. Lactated Ringer's
- C. 5% Dextrose in water
- D. 0.45% Sodium Chloride
Correct Answer: B
Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.
When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
- A. Obtain arterial blood gases (ABGs) before the procedure.
- B. Explain that the client may be positioned in five different ways.
- C. Assist the patient into a position that will allow gravity to move secretions.
- D. Encourage the client to practice deep breathing throughout the procedure.
Correct Answer: C
Rationale: The correct approach when performing postural drainage on a client with COPD is to assist the patient into a position that allows gravity to help move secretions. This position helps drain secretions from specific segments of the lungs. Obtaining arterial blood gases (Choice A) is not directly related to postural drainage. While the client may be placed in multiple positions during postural drainage, the key is to position them to facilitate the movement of secretions, not just any five positions as mentioned in Choice B. Encouraging deep breathing (Choice D) is a good nursing intervention for overall respiratory health but is not specifically related to the technique of postural drainage.
When assessing an adolescent with depression, what is the most important question for the nurse to ask?
- A. What is causing your feelings of depression?
- B. Have you ever thought about suicide?
- C. What actions can we take to improve your mood?
- D. Would you like your friends to come over?
Correct Answer: B
Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.
A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?
- A. Neutralizes stomach acid
- B. Decreases gastric acid secretion
- C. Covers the ulcer site and protects it from acid
- D. Improves gastric motility
Correct Answer: C
Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.