Nokea
The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply.
- A. Adhere to the child's home routine when possible during hospitalization
- B. Encourage parents to bring the child's favorite toy from home
- C. Have the parents step out of the room during procedures
- D. Promote a quiet sleep environment with reduced stimuli
- E. Provide a parent's shirt for the child to hold during procedures
Correct Answer: A,B,D,E
Rationale: Following the home routine (A), providing familiar toys (B), ensuring a quiet sleep environment (D), and offering a parent's shirt (E) promote comfort and security for a 6-month-old.
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A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
- A. A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns.
- B. I will clean the injection site with an antiseptic swab before administration.
- C. I will draw the medication into a 1-mL syringe.
- D. The medication should be administered into the deltoid muscle.
Correct Answer: D
Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct Answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup.
The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?
- A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours
- B. Client with a do-not-resuscitate prescription who has swelling at the IV site
- C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
- D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag
Correct Answer: A
Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.