Nokea
The most appropriate means of rehydration of a 7-month-old with diarrhea and mild dehydration is:
- A. Oral rehydration therapy with an electrolyte solution
- B. Replacing milk-based formula with a lactose-free formula
- C. Administering intraveneous Dextrose 5% 1/4 normal saline
- D. Offering bananas, rice, and applesauce along with oral fluids
Correct Answer: A
Rationale: Oral rehydration therapy with electrolyte solutions is the standard for mild dehydration in infants, as it effectively restores fluid and electrolyte balance.
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The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: safety is a priority for the client who is at high risk for infection
A client with cancer who is receiving chemotherapeutic drugs has been given injections of (pegfilgastrin) Neulasta. Which laboratory value reveals that the drug is producing the desired effect?
- A. Hemoglobin of 13.5 g/dL
- B. White blood cells count of 6,000/mm
- C. Platelet count of 300,000/mm
- D. HCT 39%
Correct Answer: B
Rationale: Pegfilgrastim (Neulasta) stimulates white blood cell production. A WBC count of 6,000/mm indicates the drug is effective in preventing neutropenia.
A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?
- A. Notify physician.
- B. Administer oxygen.
- C. Assess client and reposition pulse oximeter.
- D. Collect an arterial specimen for ABGs.
Correct Answer: C
Rationale: Assessing and repositioning the pulse oximeter (C) checks for false readings first. Oxygen (B), notifying physician (A), or ABGs (D) follow if needed.
An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls outside the scope of practice of an LPN?
- A. administer oral medications to a client
- B. insert a nasogastric tube
- C. care for a patient with a tracheostomy
- D. develop a nursing care plan
Correct Answer: D
Rationale: Developing a nursing care plan requires assessment and critical thinking, which are RN responsibilities. LPNs can perform the other tasks within their scope.