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The nurse is assessing the child's ear with an otoscope prior to administering medications to treat persistent otitis media. Which assessment finding should the nurse expect?
- A. otoscope_1.PNG
- B. otoscope_2.PNG
- C. otoscope_3.PNG
- D. otoscope_4.PNG
Correct Answer: A
Rationale: A: This shows otitis media characterized by a bulging contour to the tympanic membrane, unclear ossicular landmarks, and yellowish middle ear effusion. B: This shows a perforated tympanic membrane, not otitis media. C: This shows a normal left ear tympanic membrane. The ossicular landmarks can be identified through the tympanic membrane. The nurse would not expect to see a normal tympanic membrane when the child has persistent otitis media. D: This shows the presence of a foreign body in the ear canal.
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Client education by the nurse entails:
- A. Telling the client everything about his disease, what is going to happen in the course of the disease, and the outcome
- B. Giving information to the client that is accurate and understandable
- C. Telling the client that the pain he experiences might not be real
- D. Giving the client medication when pain is experienced
Correct Answer: B
Rationale: Client education entails giving the client accurate and understandable information to promote understanding and engagement in their care. The other options are either inappropriate or incomplete.
The nurse is observing a client self-administer two medications that are in a crushable pill form through their G tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following administration of the medications.
- C. The client mixes their medications with their tube-feeding formula.
- D. The client mixes each medication separately in warm water.
Correct Answer: C
Rationale: Medication should not be mixed with tube-feeding formula or other medications. The G-tube should be flushed before, between, and after the medications, and the client should remain in the Semi-Fowler's position for at least 30 minutes after medications are administered.
The LPN is caring for a 9 month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
- A. She prefers crawling and is making no attempt to walk.
- B. She seems distressed with new adults.
- C. She does not respond to her own name.
- D. She only babbles "mama" and "dada."
Correct Answer: C
Rationale: By 9 months, children should be babbling simple words and crawling, and they should recognize and respond to their own name. They may begin attempting to walk or may just be starting to attempt to pull themselves up to stand. Strangers often produce fear or anxiety in infants this age.
High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:
- A. the inability of the kidneys to excrete the drug metabolites
- B. rapid cell catabolism
- C. toxic effects of the prophylactic antibiotics that are given concurrently
- D. the altered blood pH from the acid medium of the drugs
Correct Answer: B
Rationale: Chemotherapy causes rapid cell destruction, releasing uric acid as a metabolite, which can elevate levels and risk conditions like gout or kidney stones.
Which of the following is least appropriate when caring for a stable postpartum client?
- A. Assess the location and height of the fundus.
- B. Conduct a family assessment, including the mother's future plans for going back to work, if applicable.
- C. Monitor the client for bleeding.
- D. Provide perineal care.
Correct Answer: B
Rationale: A family assessment is more appropriate after the client(s) have been discharged from the hospital. In the immediate postpartum stage, the nurse should provide perineal care, monitor for bleeding, and assess the location and height of the fundus.