Nokea
The nurse is caring for a preschooler who needs stitches resulting from an injury received during play in the yard. What would be the most appropriate way to prepare the child for the treatment he will receive?
- A. Tell the child the nurse and the doctor will 'make things all better.'
- B. Use dolls and explain through play and simulation what will be done.
- C. Explain to the child slowly and precisely the steps that will be taken in his treatment.
- D. Tell the child that he will have minimal scarring and that any marks will diminish over time.
Correct Answer: B
Rationale: Play-based explanation with dolls engages a preschooler's developmental level, effectively preparing them for stitches.
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The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive a similar 'shot' before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section
- A. contains a lower overall dosage of medication than is given before general surgery.
- B. contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- C. contains reduced amounts of narcotics than are given before general surgery.
- D. contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: Preoperative medications for cesarean sections typically include reduced amounts of narcotics to minimize the risk of respiratory depression in the newborn, as narcotics cross the placental barrier. Sedatives and hypnotics are used in similar doses as in general surgery, and the overall dosage is not necessarily lower.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
The patient with DM has flu.
Which nursing action is more appropriate?
- A. Frequent monitoring of blood glucose.
- B. Expected increase in the patient insulin requirement.
- C. Implement respiratory isolation.
- D. Monitor the patient's respiratory status frequently.
Correct Answer: A
Rationale: Flu can disrupt glucose control, making frequent monitoring critical.
A client with seizure disorder is to receive Dilantin (Phenytoin) and Phenobarbital. The nurse knows that when she administers Phenobarbital and Dilantin (Phenytoin):
- A. A larger dose of Phenobarbital might be required.
- B. A smaller dose of Phenobarbital might be required.
- C. There will be no need to alter the amount of Phenobarbital.
- D. The two drugs cannot be given together.
Correct Answer: A
Rationale: Phenytoin induces liver enzymes, potentially reducing phenobarbital levels, so a larger dose of phenobarbital may be needed.
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
- A. Restrain her so she will not wander in the halls
- B. Ask her roommate to call the nurse whenever she leaves the room
- C. Punish her when she gets in a bed other than her own
- D. Put her favorite picture on the door to her room
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.