Nokea
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. What is priority in teaching the child and family about this drug?
- A. The child should carry a nasal spray for emergency use
- B. The family must observe the child for dehydration
- C. Parents should administer the daily intramuscular injections
- D. The client needs to take daily injections in the short-term
Correct Answer: A
Rationale: Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.
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In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
- A. Assess the brachial pulses
- B. Breathe once every 5 compressions
- C. Use both hands to apply chest pressure
- D. Compress 80-90 times per minute
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements?
- A. I should not operate heavy machinery.
- B. I should drink only five glasses of liquid per day.
- C. This medication will cause my urine to turn orange.
- D. I should eat dried apricots each day.
Correct Answer: D
Rationale: Hydrochlorothiazide causes potassium loss; eating potassium-rich apricots indicates understanding. Options A, B, and C are incorrect.
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.