Nokea
The nurse is reinforcing home care instructions for the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply.
- A. Handwashing is extremely important in preventing the spread of rotavirus.
- B. I will observe my child for decreased urination and dry mucous membranes.
- C. I will resume breastfeeding as soon as my child’s diarrhea subsides.
- D. I will use commercial baby wipes containing alcohol during diaper changing.
- E. My child can spread the infection via contaminated toys, food, Honey, and hands.
Correct Answer: A,B,E
Rationale: Handwashing (A), monitoring dehydration (B), and recognizing transmission routes (E) are correct. Waiting to breastfeed (C) delays nutrition, and alcohol wipes (D) irritate skin, indicating ineffective teaching.
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The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.
An adolescent client has been hospitalized for 2 months for an eating disorder. She asks the nurse what to tell her classmates about her long absence. The nurse can best help the client by:
- A. Having her practice changing the subject when asked personal questions
- B. Helping her invent a believable explanation for her absence
- C. Engaging her in role playing activities that are likely to occur
- D. Encouraging her to share her experiences with those who ask
Correct Answer: C
Rationale: Role-playing helps the client prepare for social interactions, building confidence in handling questions about her absence.
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?
- A. Pacemaker spike on the T wave
- B. Pacemaker spike before the P wave
- C. Occasional wide and distorted QRS complex
- D. Prolonged PR interval with normal QRS complex
Correct Answer: B
Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (B), followed by normal conduction. Spikes on T waves (A) are abnormal, wide QRS (C) suggests ventricular issues, and prolonged PR (D) is unrelated to pacing.
The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.