Nokea
The home health nurse is contributing to the plan of care for a 1-year-old client recently diagnosed with failure to thrive. Which of the following interventions should the nurse recommend including in the client's plan of care? Select all that apply.
- A. Assess overall parenting skills and access to resources
- B. Observe both the client and the parents during feedings
- C. Monitor the client's height, weight, and head circumference
- D. Ask the parents about the client's dietary intake over the past 24 hours
- E. Discuss with the parents the need to insert a nasogastric tube for enteral feedings
Correct Answer: A,B,C,D
Rationale: Assessing parenting, observing feedings, monitoring growth, and reviewing intake identify causes of failure to thrive. Nasogastric tubes are not initially indicated.
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A client with leukemia has been receiving injections of Neulasta (pegfilgrastim). Which laboratory value reveals that the drug is producing the desired effect?
- A. Hemoglobin of $13.5 \mathrm{~g} / \mathrm{dL}$
- B. White blood cell count of $6,000 / \mathrm{mm}$
- C. Platelet count of $300,000 / \mathrm{mm}$
- D. Iron level of $75 \mu \mathrm{g} / \mathrm{dL}$
Correct Answer: B
Rationale: Neulasta (pegfilgrastim) stimulates the production of neutrophils, a type of white blood cell, to reduce the risk of infection in clients with neutropenia. A white blood cell count of 6,000/mm indicates an increase in white blood cells, showing the drug's desired effect. Hemoglobin relates to red blood cells, platelet count relates to clotting, and iron level is unrelated to Neulasta's action.
A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?
- A. Punish the client if she becomes disruptive.
- B. Give the client extra privileges when she is not disruptive for a day.
- C. Remind the client what she is supposed to do at regular intervals.
- D. Ask the client what she sees as good behavior.
Correct Answer: B
Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.
The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply.
- A. 38-year-old with methicillin-resistant Staphylococcus aureus
- B. 42-year-old with Clostridium difficile diarrhea
- C. 69-year-old with pertussis infection
- D. 72-year-old with vancomycin-resistant Enterococcus
- E. 80-year-old with influenza
Correct Answer: A,B,D
Rationale: MRSA, C. difficile, and VRE require contact precautions due to direct contact transmission. Pertussis and influenza require droplet precautions.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.