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The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.
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The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.