Nokea
The nurse is planning care for a 6-month-old client admitted with bacterial meningitis. Which nursing action is the priority?
- A. Apply padding to the crib side rails
- B. Document head circumference daily
- C. Implement a low-stimuli environment
- D. Initiate antibiotic therapy as prescribed
Correct Answer: D
Rationale: Prompt antibiotic therapy is critical to treat bacterial meningitis and prevent complications or death, making it the priority. A, B, and C are important but secondary; padding prevents injury, daily head circumference monitors for hydrocephalus, and a low-stimuli environment reduces seizure risk, but none address the infection directly.
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The nurse is preparing to administer scheduled medications to assigned clients. Which of the following medications should the nurse hold for clarification prior to administering?
- A. magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.41 mmol/L)
- B. calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)
- C. clopidogrel for a client with a platelet count of 70,000/mm³ (70 × 10â¹/L)
- D. metformin for a client with a hemoglobin A1c level of 11%
Correct Answer: C
Rationale: Clopidogrel increases bleeding risk in a client with low platelets (70,000/mm³), requiring clarification. The other medications align with the clients' conditions.
The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider?
- A. The client ate a full breakfast that morning
- B. The client has an implantable cardiovascular defibrillator (ICD)
- C. The client is allergic to povidone-iodine
- D. The client took all prescribed cardiac medications before arriving
Correct Answer: B
Rationale: An ICD is a contraindication for MRI due to magnetic interference, requiring immediate reporting. Other findings are less critical.
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
The nurse is making a home visit to the mother of an 8-lb baby boy born five days ago. Which observation indicates that the mother understands the care of the newborn?
- A. The mother is concerned about the fact that the baby has a soft stool after every breast feeding.
- B. The mother gives the baby a sponge bath but does not put him in a tub.
- C. The mother cleans the circumcised penis with alcohol when changing the diaper.
- D. The mother nurses the baby hourly.
Correct Answer: B
Rationale: Sponge baths are appropriate for newborns until the umbilical cord falls off, indicating proper care. Soft stools are normal, alcohol may irritate circumcision sites, and hourly nursing is excessive.
A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.
- A. Avoid irritants such as acidic, spicy foods
- B. Discourage the use of topical analgesics
- C. Encourage liquid nutritional supplements
- D. Perform oral hygiene once per day
- E. Use artificial saliva to control dryness
Correct Answer: A,C,E
Rationale: Avoiding irritants reduces mucosal irritation. Liquid supplements ensure adequate nutrition when swallowing is difficult. E: Artificial saliva alleviates xerostomia, a common side effect. B is incorrect as topical analgesics may be beneficial for pain relief. D is incorrect as frequent oral hygiene is needed to prevent infections and maintain oral health.