Nokea
The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?
- A. Replace latex-containing devices in the OR with alternate synthetic materials
- B. Administer an antihistamine before surgery.
- C. Notify the surgeon about the client's allergy to bananas.
- D. Prepare to administer an epinephrine injection during surgery
Correct Answer: A
Rationale: Banana allergy is associated with latex allergy. Replacing latex-containing devices prevents potential allergic reactions during surgery.
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Which information should the nurse know when caring for a child with Kawasaki disease?
- A. A child’s fever is usually responsive to antibiotics within 48 hours.
- B. The principal area of involvement is the joints.
- C. Aspirin is contraindicated.
- D. Therapeutic management includes administration of gamma globulin and aspirin.
Correct Answer: D
Rationale: High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of the therapy.
What should the nurse assess prior to administering digoxin? (Select all that apply.)
- A. Sclera
- B. Apical pulse rate
- C. Cough
- D. Liver function test
Correct Answer: B
Rationale: Because digoxin decreases the heart rate, the apical pulse should be assessed. If the HR is below 60 beats per minute, digoxin should not be administered.
A 12-month-old child who had repair of a congenital heart defect at 8 months of age has a normal exam and is not taking any medications. The nurse practitioner will contact the child's cardiologist to discuss whether the child needs which medication?
- A. Amoxicillin
- B. Capoten
- C. Digoxin
- D. Furosemide
Correct Answer: A
Rationale: Children who have had complete repair of congenital heart defect (CHD) should have subacute bacterial endocarditis (SBE) prophylaxis with amoxicillin for 6 months after the procedure.
Mental retardation is found in all the following:
- A. Trisomy 21
- B. Morquio syndrome
- C. Homocystinuria
- D. Ehlers-Danlos syndrome
Correct Answer: A
Rationale: Trisomy 21 (Down syndrome) is a well-known cause of mental retardation. Morquio syndrome, Homocystinuria, and Ehlers-Danlos syndrome are not typically associated with mental retardation.
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns and dietary intake
- B. Level and amount of physical activity
- C. Color and consistency of feces
- D. Presence and activity of bowel sounds
Correct Answer: A
Rationale: Eating patterns can affect the pain and inflammation in chronic pancreatitis, making this data crucial.