Nokea
Which of the following safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
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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.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
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.
Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian?
- A. You should cut and file your child's fingernails frequently.
- B. Cystic fibrosis
- C. You should apply a thick layer of pimecrolimus cream to your child's lesions.
- D. Your child will experience occasional flare-ups of this condition.
- E. Your child's condition is contagious when lesions are present.
- F. You can apply gloves to your child's hands.
- G. "You should apply emollients to your child's skin after bathing**
Correct Answer: A,B,D,F,G
Rationale: The correct answer includes multiple important statements for the discharge instructions.
A: Cutting and filing fingernails prevent scratching and potential skin damage.
B: Cystic fibrosis is relevant medical information for the child's care.
D: Informing about occasional flare-ups helps prepare the guardian.
F: Applying gloves prevents scratching and potential skin infection.
G: Emollients maintain skin hydration and prevent dryness. These instructions promote optimal care and management of the child's condition. Other choices are incorrect as they either provide irrelevant information (C), are not necessary for the child's care (E), or do not directly contribute to the child's well-being (B).
Which of the following oils should the nurse recommend?
- A. Lavender
- B. Eucalyptus
- C. Jasmine
- D. Tea tree
Correct Answer: A
Rationale: The nurse should recommend lavender oil because it is known for its calming and relaxing properties, which can help reduce stress and promote better sleep. Lavender oil has therapeutic benefits for anxiety and insomnia, making it a suitable choice. Eucalyptus is more commonly used for respiratory issues, jasmine for relaxation, and tea tree for skin conditions. Lavender stands out as the most appropriate option based on the context of the question.