Nokea
The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
- A. I should report a sudden increase in bile output.
- B. The client should be in a semi-Fowler's position to promote drainage.
- C. The drainage system should be kept below the level of the gallbladder.
- D. I will clamp the tube if the client becomes nauseated or begins to vomit.
Correct Answer: D
Rationale: Clamping the T-tube during nausea or vomiting risks pressure buildup; it should be reported instead. Other statements are correct.
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The clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?
- A. I will give Tylenol for the fever.
- B. I will give cough syrup every night at bedtime.
- C. Sips of warm fluids during a croup attack will help.
- D. I will place a cool-mist humidifier next to my child's bed.
Correct Answer: B
Rationale: The mother needs to be instructed that cough syrup and cold medicines should not be administered because they may dry and thicken secretions, worsening croup symptoms. Acetaminophen (Tylenol) is appropriate for reducing fever. Sips of warm fluids help relax the vocal cords and thin mucus. A cool-mist humidifier is recommended to keep the air moist and reduce airway irritation.
The nurse is planning discharge teaching for the parents of a child who sustained a head injury and who is now receiving tapering doses of dexamethasone. The nurse plans to make which statement to the parents?
- A. This medication decreases the chance of infection.
- B. This medication will be discontinued after two doses.
- C. If your child's face becomes puffy, the medication dose needs to be increased.
- D. This medication is tapered to decrease the chance of recurring swelling in the brain.
Correct Answer: D
Rationale: Dexamethasone sodium phosphate is a corticosteroid. The rebounding of cerebral edema is a side effect of dexamethasone sodium phosphate withdrawal if it is done abruptly. This medication decreases inflammation rather than infection. Facial edema is a common side effect that disappears when the medication is discontinued.
A mother brings her 6-month-old baby to the nurse practitioner for a routine well-baby check. Which behavior reported by the mother is concerning to the nurse?
- A. looks at self in a mirror
- B. brings things to mouth
- C. does not laugh or make squealing sounds
- D. begins to sit without support
Correct Answer: C
Rationale: Lack of laughing or squealing at 6 months suggests a developmental delay, as these are expected social behaviors. Other behaviors are age-appropriate.
The nurse has completed instructions regarding diet and fluid restriction for the client diagnosed with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu?
- A. Jell-O
- B. Sherbet
- C. Ice cream
- D. Angel food cake
Correct Answer: D
Rationale: For fluid-restricted diets in chronic kidney disease, clients should avoid foods liquid at room temperature like Jell-O, sherbet, and ice cream, which count as fluid intake. Angel food cake is a solid dessert, allowing more fluid intake by drinking to alleviate thirst.
A 9-month-old child is registered to attend a local childcare clinic. Upon initial intake, the nurse discovers the child has received the first and second dose of the hepatitis B vaccine. What is the best course of action for the nurse to recommend to the parents?
- A. no action; a third dose of the vaccine is not recommended
- B. immediately inoculate the child given the high risk of not having a third vaccine
- C. wait until the child is 12 months to give the vaccine
- D. schedule the child for the third vaccine at the earliest convenience
Correct Answer: D
Rationale: The hepatitis B vaccine requires three doses, with the third typically given between 6-18 months. Scheduling the third dose at the earliest convenience ensures timely protection. Option A is incorrect, B is unnecessarily urgent, and C delays protection.