Nokea
The nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving methotrexate. Which laboratory value would be most concerning?
- A. WBC 4,000/mm3
- B. Platelet count 150,000/mm3
- C. Hemoglobin 13 g/dL
- D. Serum creatinine 1.2 mg/dL
Correct Answer: A
Rationale: Methotrexate can cause bone marrow suppression. A WBC of 4,000/mm3 (A) indicates leukopenia, increasing infection risk, and is most concerning. Platelets (B), hemoglobin (C), and creatinine (D) are within normal limits.
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In cleansing the perineal area around the site of catheter insertion, the nurse would:
- A. Wipe the catheter toward the urinary meatus
- B. Wipe the catheter away from the urinary meatus
- C. Apply a small amount of talcum powder after drying the perineal area
- D. Gently insert the catheter another 1/2 inch after cleansing to prevent irritation from the balloon
Correct Answer: B
Rationale: Wiping away from the urinary meatus removes microorganisms from the insertion point, decreasing the risk of bladder infection. The other options increase infection risk or are inappropriate.
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. I understand your concern and will assist you with a referral.'
- B. Try not to worry because you will just upset your child.'
- C. Just ignore the behavior and it should disappear by age 8.'
- D. This is appropriate behavior for a preschooler and should not be a concern.'
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
The priority nursing goal when working with an autistic child is:
- A. To establish trust with the child
- B. To maintain communication with the family
- C. To promote involvement in school activities
- D. To maintain nutritional requirements
Correct Answer: A
Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority. To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.
Which of the following diagnoses require droplet precautions?
- A. Varicella
- B. Rubella
- C. Streptococcal pharyngitis
- D. Scarlet fever
- E. Shigella
- F. Hepatitis A
Correct Answer: B, C, D
Rationale: Rubella (B), streptococcal pharyngitis (C), and scarlet fever (D) are transmitted via respiratory droplets, requiring droplet precautions. Varicella (A) requires airborne precautions, while Shigella (E) and hepatitis A (F) are transmitted fecally-orally, requiring contact precautions.
Which of the following is an expected finding in a child with osteogenesis imperfecta?
- A. Blue sclera
- B. Hutchinson's teeth
- C. Anisocoria
- D. Pectus excavatum
Correct Answer: A
Rationale: Blue sclera is a hallmark of osteogenesis imperfecta due to thin connective tissue in the eyes. Hutchinson’s teeth are associated with congenital syphilis anisocoria is unequal pupil size and pectus excavatum is a chest deformity not specific to this condition.