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The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
- A. Administer surfactant
- B. Provide high-flow oxygen
- C. Initiate antibiotic therapy
- D. Perform chest physiotherapy
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
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The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions is most important?
- A. Avoid swimming alone.
- B. Take medications at bedtime only.
- C. Use a soft toothbrush.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Avoiding swimming alone is critical for safety in epilepsy to prevent drowning during a seizure.
When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:
- A. Neutralizing gastric acid.
- B. Reducing gastric acid secretion.
- C. Coating the stomach lining.
- D. Increasing gastric motility.
Correct Answer: B
Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.
You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the client and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer's disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband?
- A. You should advise the couple to move closer to their children so that they can care for their father.
- B. You should teach the wife about this progressive disease and the need to promote as much independence as possible.
- C. You should teach the wife about this progressive disease and the need to do all that she can for the husband to avoid his depression and frustration.
- D. You should advise the couple to decrease their social activities in order to preserve the husband's dignity and self-esteem.
Correct Answer: B
Rationale: Educating the wife about Alzheimer's disease and promoting the husband's independence as much as possible supports safety and dignity while respecting her role as a caregiver with physical limitations.
When a child is able to grasp the idea that a ball continues to exist even though his parent placed the ball under a hat, the child is in which of the following stages in the development of logical thinking, according to Piaget?
- A. Sensorimotor.
- B. Preoperational.
- C. Concrete operations.
- D. Formal operations.
Correct Answer: A
Rationale: Object permanence, understanding that objects exist when out of sight, develops during the sensorimotor stage (birth to 2 years) per Piaget's theory.