Nokea
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
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A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.
Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
- A. Fever
- B. Red urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.
The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin:
- A. Slows contractions of the heart
- B. Dilates coronary blood vessels
- C. Increases the ventricular fill time
- D. Strengthens contractions of the heart
Correct Answer: B
Rationale: Nitroglycerin dilates coronary blood vessels, improving blood flow to the myocardium and relieving angina.
A client is admitted with a blood alcohol level of 180 mg/dL. The nurse recognizes that the alcohol in the client's system should be fully metabolized within:
- A. 3 hours
- B. 5 hours
- C. 7 hours
- D. 9 hours
Correct Answer: D
Rationale: A blood alcohol level of 180 mg/dL (0.18%) typically takes about 9 hours to metabolize, assuming a metabolism rate of 0.02% per hour.
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?
- A. Hemoglobin
- B. Creatinine
- C. Blood glucose
- D. White blood cell count
Correct Answer: C
Rationale: TPN's high dextrose content requires glucose monitoring to prevent hyperglycemia.