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A charge nurse is observing a staff nurse who is caring for a child who has pertussis.
Which of the following actions by the staff nurse indicates an understanding of infection control practices?
- A. Maintains droplet precautions while the child is coughing and sneezing.
- B. Applies a face mask after entering the child's room.
- C. Wears gloves when assisting the child to the bathroom.
- D. Follows airborne precautions by wearing an N95 respirator while caring for the child.
Correct Answer: A
Rationale: The correct answer is A because maintaining droplet precautions while the child is coughing and sneezing is essential for preventing the spread of infection through respiratory droplets. This action shows understanding of infection control practices by implementing specific measures to reduce transmission of pathogens. Choice B is incorrect as wearing a face mask after entering the room does not provide adequate protection during exposure to respiratory secretions. Choice C is incorrect as gloves are not sufficient for preventing transmission of respiratory infections. Choice D is incorrect as airborne precautions are not necessary for droplet precautions.
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A nurse is caring for a 5-year-old child who has nephrotic syndrome.
Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
A nurse is caring for a child who has disseminated intravascular coagulation.
Which of the following laboratory findings should the nurse expect?
- A. Decreased prothrombin time
- B. Increased Hgb level
- C. Increased RBC
- D. Decreased platelet count
Correct Answer: D
Rationale: The correct answer is D: Decreased platelet count. This is expected in a patient with thrombocytopenia, which is a condition characterized by low platelet levels. Thrombocytopenia can lead to abnormal bleeding and bruising due to impaired blood clotting.
A: Decreased prothrombin time would not be expected in thrombocytopenia, as it measures the clotting ability of the plasma, not platelets.
B: Increased Hgb level and C: Increased RBC levels are not typically associated with thrombocytopenia.
In summary, a decreased platelet count is the most relevant laboratory finding to expect in a patient with thrombocytopenia.
A nurse is assessing a 5-month-old infant.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
A nurse is providing teaching for a 20-year-old adolescent who has syphilis.
Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.
A nurse in the emergency department is caring for an adolescent who is requesting testing for STIs.
Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.