Nokea
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
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After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.
Acyclovir (Zovirax) is the agent of choice for which of the following infections?
- A. HIV
- B. AIDS
- C. candida
- D. herpes
Correct Answer: D
Rationale: Acyclovir is an antiviral effective in shortening the duration of infection in herpes. It is used in HIV and AIDS to treat opportunistic viral infections but is not a primary AIDS drug. Candida is a fungus responsive to antifungal medication.
The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?
- A. Apply the wrist restraints as prescribed
- B. Request an order for a right ankle restraint also
- C. Request an order for sedation instead of restraints
- D. Question the order; restraints will increase the client's agitation
Correct Answer: B
Rationale: An ankle restraint is needed to prevent leg movement that could dislodge the femoral arterial line, which wrist restraints alone cannot address.
The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?
- A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep
- B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication
- C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia
- D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site
Correct Answer: B
Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Test blood sugar every 2 hours by Accu-Check
- B. Review with family and client signs of hyperglycemia
- C. Monitor for mental status changes
- D. Check skin condition of lower extremities
Correct Answer: A
Rationale: The UAP can do standard, unchanging procedures. Testing blood sugar with an Accu-Check is a routine task that does not require clinical judgment, making it appropriate for delegation to a UAP.