Nokea
The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: Urinary output of 30 ml per hour. This indicates adequate fluid replacement without suggesting overload.
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A patient has been receiving a cardiac glycoside, a diuretic, and a vasodilator and is on bedrest. The patient's apical pulse rate is 44.
The nurse concludes that this pulse rate is most likely a result of the:
- A. Diuretic
- B. Vasodilator
- C. Bedrest regimen
- D. Cardiac glycoside
Correct Answer: D
Rationale: Cardiac glycosides like digoxin can cause bradycardia, especially at a pulse of 44.
The nurse is assigned to a patient newly diagnosed with active tuberculosis.
Which of these interventions would be a priority for the nurse to implement?
- A. Have the client cough into a tissue and dispose in a separate bag
- B. Instruct the client to cover the mouth with a tissue when coughing
- C. Reinforce that everyone should wash their hands before and after entering the room
- D. Place client in a negative pressure private room and have all who enter the room use masks with shields
Correct Answer: D
Rationale: A negative pressure room and masks prevent airborne transmission of tuberculosis, a priority for infection control.
Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy.
The nurse would suggest that the appropriate car seat for the child is
- A. the rear-facing seat.
- B. the front facing seat.
- C. the booster seat with car seat belt.
- D. the back seat.
Correct Answer: C
Rationale: A booster car seat is appropriate for a bigger child like a 4-year-old, ensuring proper restraint and safety.
The importance of monitoring blood sugar, activity level, and insulin doses is to
adjust the activity level based on the blood sugar level.
- A. adjust the diet and insulin doses as the activity level increases or decreases.
- B. adjust the diet and activity level based on the blood sugar level.
- C. adjust the insulin doses based on the sugar level in the urine.
Correct Answer: B
Rationale: If a patient injects too much insulin, exercises too much in relation to carbohydrate consumed, or does not eat enough or at the appropriate times, the blood glucose level can fall low enough to cause hypoglycemia. Adjusting diet and insulin doses based on activity level helps maintain balance.
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
- A. Weekly Z-track injections are required for control.
- B. Daily intramuscular injections are required for control.
- C. Intramuscular injections once a month will maintain control.
- D. Oral tablets of vitamin B12 taken daily will keep the symptoms under control.
Correct Answer: C
Rationale: Monthly B12 injections maintain control in pernicious anemia due to absorption deficits.