Nokea
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
- A. What is the best nursing intervention for a 14-year-old with an acute exacerbation of ulcerative colitis?
- B. Encourage her mother to room in with her.
- C. Provide information on the hospital school program.
- D. Ask if she would like to have visits from friends.
- E. Involve her in planning her daily schedule.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.
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The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: Nurses are more satisfied when opportunities exist for autonomy and control. Self-scheduling improves team morale by giving staff more control over their work schedules.
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Lithium level of 2.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Creatinine 1.0 mg/dL.
Correct Answer: A
Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range 0.6–1.2 mEq/L), risking seizures or coma, requiring immediate intervention. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL do not indicate complications.
A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child
The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. White blood cell count of 3,000/mm^3.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious carbamazepine side effect. Options B, C, and D are normal.