Nokea
The mother of a 2-year-old asks the nurse when she should schedule her son's first dental visit. The nurse's response is based on the knowledge that most children have all their deciduous teeth by:
- A. 15 months
- B. 18 months
- C. 24 months
- D. 30 months
Correct Answer: D
Rationale: Most children have all 20 deciduous teeth by 30 months, guiding the timing of the first dental visit.
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Which statement is true regarding the infant's susceptibility to pertussis?
- A. If the mother had pertussis, the infant will have passive immunity.
- B. Most infants and children are highly susceptible from birth.
- C. The newborn will be immune to pertussis for the first few months of life.
- D. Infants under 1 year of age seldom get pertussis.
Correct Answer: B
Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.
An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?
- A. Reassure the client that the room number will not affect his surgery outcome.
- B. Contact the admissions department and request that the client be reassigned to a different room.
- C. Ask the physician for medication to relax the client.
- D. Ask the son to stay with the client to reassure him.
Correct Answer: B
Rationale: Reassigning the client to a different room (B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (A), medication (C), or family presence (D) may not fully alleviate the specific concern.
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
When caring for the child with autistic disorder, the nurse should:
- A. Take the child to the playroom to be with peers
- B. Assign a consistent caregiver
- C. Place the child in a ward with other children
- D. Assign several staff members to provide care
Correct Answer: B
Rationale: A consistent caregiver provides stability and reduces anxiety in a child with autism.
The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
- A. I should take this medication with meals.'
- B. I need to report flulike symptoms to my doctor.'
- C. My doctor might order liver tests while I'm on this drug.'
- D. If I'm already having an asthma attack, this drug will not stop it.'
Correct Answer: A
Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.