Nokea
The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?
- A. Clear the area of any hazards
- B. Place the child on its side
- C. Restrain the child
- D. Give the prescribed anticonvulsant
Correct Answer: B
Rationale: Place the child on its side. Protecting the airway is the top priority in a seizure to ensure a patent airway and oxygenation.
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An adult is admitted through the outpatient department for elective surgery today. The client is coughing and sneezing and has a temperature of 100.6°F. What should the nurse do next?
- A. Prepare the client for surgery as scheduled
- B. Explain to the client that a cold increases risks during surgery and ask if he/she is willing to assume those risks
- C. Call the physician before continuing preparations for surgery
- D. Ask what type of anesthesia the client is receiving
Correct Answer: C
Rationale: Infection increases surgical risks; notifying the physician allows for evaluation and possible postponement.
The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
A nursing assistant is assigned to constant observation of a suicidal patient.
Which of the following statements made by the nursing assistant would require IMMEDIATE intervention by the nurse?
- A. Let's put your clothes in the dresser.'
- B. I'll stay in the bathroom with you while you take your shower.'
- C. You're going to be moved to a private room later today.'
- D. I'll be right back with something for you to eat.'
Correct Answer: D
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that something is wrong. (1) no reason to intervene (2) appropriate, client is not to be left alone for any reason (3) no reason to intervene (4) correct-client under constant observation; must not be left alone for any reason
A 56-year-old woman is receiving digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. She calls her physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for 2 days and instructs her to call back if symptoms don't subside.
The nurse should instruct the woman to
- A. make no changes in her medication schedule.
- B. wait 1 hour before taking her scheduled medications if she takes the Kaopectate.
- C. hold her scheduled medications until the diarrhea subsides.
- D. take the Lanoxin but hold the Lasix if she takes the Kaopectate.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) PO meds would be absorbed by Kaopectate not by stomach (2) correct-Kaopectate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
- A. The child was probably not exposed to it until recently.
- B. Antibodies from the mother are present for the first year of life.
- C. The symptoms do not manifest until the child is no longer breastfeeding.
- D. High fetal hemoglobin levels prevent symptoms for the first year of life.
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.