Nokea
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
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A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
An adult is admitted with nausea, vomiting, and diarrhea. The client is receiving an IV of dextrose 5% in water with 40 mEq of KCl. The nurse knows the potassium is added to do which of the following?
- A. Replace potassium lost because of vomiting and diarrhea
- B. Replace potassium that the client is not getting from his diet
- C. Stop the nausea
- D. Stop the diarrhea
Correct Answer: A
Rationale: Vomiting and diarrhea cause significant potassium loss, requiring IV potassium replacement to prevent hypokalemia.
The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
- A. Observe the wound for excess drainage
- B. Check the system for air leaks
- C. Auscultate the lungs
- D. See if the suction is turned on
Correct Answer: C
Rationale: No bubbling may indicate lung reexpansion or system issues; auscultating lungs assesses reexpansion or complications like pneumothorax. Other assessments are secondary.
A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:
- A. CNS depression that accompanies xanthine derivatives
- B. CNS stimulation that sometimes accompanies xanthine derivatives
- C. The anticholinergic effects of aminophylline
- D. Cardiovascular depression that can accompany xanthine derivatives
Correct Answer: B
Rationale: Aminophylline, a xanthine derivative, can cause CNS stimulation, leading to nervousness and shakiness. It does not typically cause CNS or cardiovascular depression or anticholinergic effects.