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The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.
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A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist client to turn, deep breathe and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
- A. An infant diagnosed with respiratory syncytial virus.
- B. A young child with a wound infected with S aureus.
- C. A teenager diagnosed with toxic shock syndrome.
- D. A teenager diagnosed with rubella (German measles).
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
- A. There is a probability of life-long complications.
- B. Cystic fibrosis results in nutritional concerns that can be dealt with.
- C. Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.
- D. You will work with a team of experts and also have access to a support group that the family can attend.
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.
The nurse is caring for a client with Ménière's disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?
- A. This enables the client to read the nurse's lips.
- B. The client does not have to turn her head to see the nurse.
- C. The nurse will have the client's undivided attention.
- D. There is a decrease in client's peripheral visual field.
Correct Answer: B
Rationale: by decreasing movement of client's head, vertigo attacks may be decreased