Nokea
The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
- A. Hold and cuddle the child frequently
- B. Encourage the child to feed himself finger food
- C. Allow the child to walk independently on the nursing unit
- D. Engage the child in games with other children
Correct Answer: B
Rationale: Encourage the child to feed himself finger food. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.
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The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2 year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid fast bacillus
Correct Answer: C
Rationale: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
The mother calls the nurse to ask when her newborn will be brought back to her room to finish feeding. The mother states that a doctor came about 30 minutes ago to take the baby for an examination and has not returned with her baby. Which action should be taken by the nurse first?
- A. Check the unit for the infant
- B. Initiate procedures for possible newborn abduction
- C. Ask other staff if they saw any physicians on the unit
- D. Check to see if the doctor is still examining the Infant
Correct Answer: B
Rationale: The suspicious circumstance of a doctor taking the baby for 30 minutes warrants immediate initiation of abduction procedures to ensure the newborn's safety.
Acyclovir (Zovirax) is the agent of choice for which of the following infections?
- A. HIV
- B. AIDS
- C. candida
- D. herpes
Correct Answer: D
Rationale: Acyclovir is an antiviral effective in shortening the duration of infection in herpes. It is used in HIV and AIDS to treat opportunistic viral infections but is not a primary AIDS drug. Candida is a fungus responsive to antifungal medication.