Nokea
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
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The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?
- A. I should offer only two options when my child is choosing things like clothes or meals.
- B. I will need to advocate for an individualized educational plan for my child.
- C. My child will most likely outgrow this disorder in early adulthood, around age 20.
- D. When talking with my child, I should focus and not be multi-tasking.
Correct Answer: C
Rationale: ADHD often persists into adulthood, so stating it will be outgrown by age 20 (C) is incorrect and requires intervention. Limiting choices (A), advocating for an IEP (B), and focusing during conversations (D) are appropriate.
The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
Which of the following nursing interventions is essential when caring for a client who is receiving Cyclophosphamide (Cytoxin)?
- A. Monitoring vital signs q 1 hour
- B. Carefully monitoring of urine output
- C. Monitoring apical pulse
- D. Assessing for signs of increased intracranial pressure
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; monitoring urine output is critical to detect blood in the urine and ensure adequate hydration.
The practical nurse (PN) is assisting with a client who is undergoing labor induction with misoprostol. The PN notes late decelerations and minimal variability on the fetal heart rate monitor. After notifying the registered nurse, what should the PN do first?
- A. Administer 10 L/min oxygen by face mask
- B. Examine the perineum to check for bloody show
- C. Palpate the client's abdomen
- D. Reposition the client to a side-lying position
Correct Answer: D
Rationale: Repositioning to a side-lying position (D) improves placental perfusion, addressing late decelerations. Oxygen (A) may follow, but repositioning is first. Perineal exam (B) and palpation (C) are less urgent.
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown below. The nurse should recognize that the client is experiencing
- A. atrial flutter
- B. sinus bradycardia
- C. normal sinus rhythm
- D. premature atrial contractions
Correct Answer: C
Rationale: Without the ECG strip, normal sinus rhythm (C) is assumed for a stable client, characterized by regular P waves, QRS complexes, and a rate of 60-100 bpm. Other options indicate abnormal rhythms.