Nokea
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.
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The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
- A. The dialysate returns become cloudy in appearance.
- B. The return of the dialysate is slower than usual.
- C. A 'tugging' sensation is noted as the dialysate drains.
- D. A feeling of fullness is felt when the dialysate is instilled.
Correct Answer: A
Rationale: Cloudy dialysate indicates possible peritonitis, a serious infection requiring immediate medical intervention to prevent complications.
The nurse is providing discharge instructions to the parents of a 6-month-old child with surgical repair for cryptorchidism. Which instruction would NOT be stressed?
- A. observe surgical site for bleeding
- B. enforce bed rest for 2-3 days
- C. palpate scrotum to check testicle location
- D. avoid strenuous activity for at least one month
Correct Answer: B
Rationale: Bed rest for 2-3 days is not typically required for cryptorchidism repair in infants, as recovery is quicker. Other instructions are critical for monitoring and safety.
How many hours of activity per day are necessary to prevent disuse syndrome with muscle atrophy and joint contracture?
- A. 6 hours
- B. 4 hours
- C. 2 hours
- D. 1 hour
Correct Answer: C
Rationale: Approximately 2 hours of activity daily (C), including range-of-motion exercises or ambulation, helps prevent disuse syndrome, muscle atrophy, and joint contractures in immobilized clients.
A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?
- A. drink orange juice to relieve discomfort
- B. drink extra milk to relieve discomfort
- C. avoid drinking from a straw
- D. rinse twice a day with antiseptic mouthwash
Correct Answer: C
Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.
The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A. A 23-year-old female complaining of headache and nausea
- B. A 76-year-old male complaining of dysuria
- C. A 56-year-old male complaining of exertional shortness of breath
- D. A 42-year-old female complaining of recent sexual assault
Correct Answer: C
Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.