Nokea
The nurse enters an infant's room and observes that the infant is responsive but is choking and turning blue. Which of the following actions should the nurse take?
- A. Initiate CPR
- B. Perform abdominal thrusts.
- C. Initiate back slaps and chest thrusts.
- D. Perform a blind sweep of the infant's mouth.
Correct Answer: C
Rationale: Back slaps and chest thrusts (C) are the appropriate intervention for a choking infant. CPR (A) is for cardiac arrest, abdominal thrusts (B) are for older children, and blind sweeps (D) are dangerous.
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Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.
- A. Administer the medication with food if nausea or diarrhea develops
- B. Complete the medication course even if the child is better
- C. Rash is a normal, expected side effect
- D. Shake the medicine well before use
- E. Use a household spoon to measure the dose
Correct Answer: A, B, D
Rationale: Taking with food (A) reduces GI upset, completing the course (B) prevents resistance, and shaking well (D) ensures proper dosing. Rash (C) is not normal and requires evaluation, and household spoons (E) are inaccurate.
A female client seen in the health department's STD clinic is diagnosed with chlamydia. Before the client leaves the clinic, the nurse should:
- A. Obtain the names and addresses of the client's sexual contacts.
- B. Tell the client to avoid alcohol while taking her prescription for Flagyl.
- C. Instruct the client to avoid sexual relations until the infection is resolved.
- D. Tell the client to douche after sexual intercourse.
Correct Answer: C
Rationale: Avoiding sexual relations prevents chlamydia spread until treatment is complete. Contact tracing is secondary, Flagyl is for trichomoniasis, and douching is harmful.
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
- A. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
- B. Client admitted with multiple sclerosis exacerbation has scanning speech
- C. Client with epilepsy puts on call light and reports having an aura
- D. Client with fibromyalgia reports pain in the neck and shoulders
Correct Answer: C
Rationale: An aura (C) indicates an impending seizure, requiring immediate intervention to ensure safety. Guillain-Barré (A), multiple sclerosis (B), and fibromyalgia (D) are less acute at this moment.