Nokea
The nurse caring for a child with congestive heart failure who will be discharged to home provides instructions to the parents regarding the administration of digoxin. Which statement by the mother indicates a need for further teaching?
- A. I will mix the medication with food.
- B. I will check my child's pulse before giving the medication.
- C. If my child vomits after I give the medication, I will not repeat the dose.
- D. I will check the dose of medication with my husband before I give the medication.
Correct Answer: A
Rationale: Digoxin is a cardiac glycoside and should not be mixed with food or formula because this method may not ensure the child receives the entire dose if the food is not fully consumed. Checking the child's pulse, not repeating the dose after vomiting, and verifying the dose with another person are correct interventions to ensure safe administration.
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The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
- A. Location 1
- B. Location 2
- C. Location 3
- D. Location 4
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most appropriate statement for the nurse to make to the child?
- A. Would you like to see my flashlight?
- B. Don't be scared, the light won't hurt you.
- C. If you will sit still, the exam will be over soon.
- D. I know you are upset. We can do this exam later.
Correct Answer: A
Rationale: Engaging the toddler by offering to show the flashlight reduces fear and encourages cooperation, suitable for this developmental stage. Other options either dismiss feelings, demand compliance, or delay the necessary exam inappropriately.
The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?
- A. Roast beef
- B. Fresh cantaloupe
- C. Broiled cheeseburger
- D. Mashed potato with gravy
Correct Answer: B
Rationale: To lower the risk of heart disease, the diet should be low in saturated fat with the appropriate number of total calories. The diet should include less red meat (roast beef, cheeseburger) and more white meat with the skin removed. Dairy products used should be low in fat, and foods with high amounts of empty calories (white gravy) should be avoided.
A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
- A. Report the abuse to the police.
- B. Provide medications to relieve pain and anxiety.
- C. Explore family and friends as support possibilities.
- D. Focus on the woman's strengths, endurance, and abilities.
- E. Avoid discussing the implications of pressing charges against the batterer.
- F. Discourage the woman from discussing the events leading to past and present abuse situations.
Correct Answer: A,B,C,D
Rationale: Tertiary prevention for repeated abuse focuses on overcoming physical and psychological effects and preventing future abuse. Appropriate interventions include reporting abuse to ensure safety, providing medications for pain and anxiety, exploring support options, and focusing on the woman's strengths to boost self-esteem. Avoiding discussions about pressing charges or past events is not helpful, as these help address implications and reduce guilt.