Nokea
The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?
- A. The medication needs to be given at bedtime to be most effective.
- B. My child will achieve a height equal to peers after receiving therapy.
- C. The medication will be discontinued when my child's bone growth ceases.
- D. Routine x-rays may be required during therapy to monitor bone lengthening.
Correct Answer: B
Rationale: Expecting equal height to peers (B) is unrealistic, as outcomes vary. Bedtime dosing (A), discontinuation at bone closure (C), and x-rays (D) are correct.
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The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?
- A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin
- B. Chooses a 1-mL tuberculin syringe with a 27-gauge, 1/4-inch needle; dons clean gloves
- C. Injects medication slowly while raising a small wheal (bleb) on the skin
- D. Inserts needle at a 10-degree angle almost parallel to the skin with the bevel up
Correct Answer: A
Rationale: Advancing until the bevel is invisible (A) is too deep for intradermal injection, requiring intervention. Syringe choice (B), wheal formation (C), and angle (D) are correct.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin
- B. Hypernatremia
- C. High serum creatinine
- D. Hyperkalemia
Correct Answer: A
Rationale: Low hemoglobin. Hemodialysis corrects electrolyte imbalances but does not improve anemia.
The nurse shows an understanding of the psychological needs of a client in isolation when he:
- A. Provides extra reading material.
- B. Alternates nursing staff.
- C. Allows phone calls from family and friends.
- D. Limits the use of a gown and gloves.
Correct Answer: C
Rationale: Allowing phone calls meets the psychological need for social connection in isolation. Reading material is helpful but less critical, alternating staff may disrupt continuity, and limiting PPE compromises safety.
An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:
- A. Strep throat
- B. Epiglottitis
- C. Laryngotracheobronchitis
- D. Bronchiolitis
Correct Answer: B
Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.