Nokea
The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?
- A. Changing the linens on the clients’ beds
- B. Restocking the bedside supplies needed for a dressing change on the upcoming shift
- C. Documenting the care provided during her shift
- D. Emptying the trash cans in the assigned client room
Correct Answer: C
Rationale: Documenting care is a legal and professional responsibility that ensures continuity of care and accurate communication between shifts.
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An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?
- A. Collect a urine specimen for culture analysis
- B. Review the client's fluid intake prior to bedtime
- C. Palpate the bladder above the symphysis pubis
- D. Obtain a fingerstick blood glucose level
Correct Answer: C
Rationale: Palpating the bladder helps assess for urinary retention, which is common in older males with prostate issues.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess urine output?
- A. Inserting a foley catheter.
- B. Weighing the diapers.
- C. Comparing intake with output.
- D. Measuring the amount of water added to the formula.
Correct Answer: B
Rationale: Weighing diapers is a non-invasive and accurate method to assess urine output in infants, which is crucial for monitoring the effectiveness of diuretic therapy.
Can parents hold their child during an echocardiogram procedure?
- A. You will be able to hold your child during the procedure.
- B. Your child can be active during the procedure, but can’t sit in your lap.
- C. Your child must lie quietly; sometimes a mild sedative is administered before the procedure.
- D. The procedure is invasive so your child will be restrained during the echocardiogram.
Correct Answer: C
Rationale: Although an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychological preparation for the test. The distraction of a video or movie is often helpful.
The following statements about immunoglobulins are false:
- A. IgG is not transferable across the placenta
- B. IgM is usually a pentamer
- C. IgE levels are raised in parasitic infestations
- D. IgD is important in antibody dependent cytotoxicity
Correct Answer: A
Rationale: IgG is not transferable across the placenta: IgG is the only immunoglobulin that crosses the placenta to provide passive immunity to the fetus.
The patient experiences a headache and is unable to move the left side of his body. The most likely cause is
- A. embolic stroke
- B. cerebral thrombosis
- C. cerebral abscess
- D. moyamoya disease
Correct Answer: A
Rationale: Embolic stroke is a common complication of cyanotic congenital heart disease.