Nokea
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
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Methylphenidate is prescribed for a child with a diagnosis of attention deficit hyperactivity disorder (ADHD). At which time of day should the nurse instruct the mother to administer the medication?
- A. Before dinner and at bedtime
- B. At the noontime and evening meals
- C. In the morning after breakfast and at bedtime
- D. Before breakfast and before the noontime meal
Correct Answer: D
Rationale: Methylphenidate is a central nervous stimulant and should be taken before breakfast and before the noontime meal. It should not be taken in the afternoon or evening because the stimulating effect causes insomnia. The remaining options are incorrect.
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
- A. Consult the pharmacist regarding identification of the medications.
- B. Show pictures to the client from the Physician's Desk Reference to identify the medications.
- C. Consult the previous medical record and notify the physician regarding medications that must be ordered.
- D. Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Correct Answer: D
Rationale: Having medications brought in original vials ensures accurate identification, promoting safe administration.
A client with a diagnosis of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Etanercept, a TNF inhibitor, increases the risk of infections due to immune suppression.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?
- A. Hypostatic pneumonia.
- B. Pulmonary hypertension.
- C. Orthostatic hypotension.
- D. Fluid imbalances.
Correct Answer: D
Rationale: TPN can cause fluid imbalances due to high glucose and volume loads, requiring close monitoring of intake, output, and electrolytes.
An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
- A. Measurement of urine specific gravity.
- B. Assessment of bowel sounds.
- C. Characteristics of the first stool.
- D. Measurement of gastric output.
Correct Answer: A
Rationale: Urine specific gravity is unrelated to assessing for ileus, which involves monitoring bowel sounds, stool characteristics, and gastric output to detect gastrointestinal function.