Nokea
The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
- A. Dandelion leaves
- B. Pencils
- C. Old paint
- D. Stuffing from toy animals
Correct Answer: C
Rationale: Dandelion leaves are not a source of lead. Pencils are not a source of lead poisoning. Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. Stuffed animals are not a source of lead.
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The nurse is preparing to administer insulin to a client with type 1 diabetes. The client is to receive 10 units of NPH insulin and 5 units of regular insulin in the same syringe. Which action is correct?
- A. Draw up the regular insulin first, then the NPH insulin.
- B. Draw up the NPH insulin first, then the regular insulin.
- C. Mix the insulins in a separate vial before drawing up.
- D. Administer the insulins in two separate injections.
Correct Answer: A
Rationale: To prevent contamination, draw up regular (clear) insulin first, then NPH (cloudy). Mixing in a vial (C) is incorrect, and separate injections (D) are unnecessary.
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their compromised immune systems.
The nurse is in the hallway and one of the visitors faints. The nurse should:
- A. Sit the victim up and lightly slap his face
- B. Elevate the victim's legs
- C. Apply a cool cloth to the victim's neck and forehead until he recovers
- D. Sit the victim up and place the head between the knees
Correct Answer: B
Rationale: Sitting the client up defeats the goal of re-establishing cerebral blood flow. Elevating the legs anatomically redirects blood flow to the cerebral area. This strategy is a nice general comfort measure after the victim has regained consciousness. This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
- A. No, but you must be able to ride on a stationary bicycle while the test is being performed.
- B. No, but you will have to lie still and the gel that is used may be cool.
- C. Yes, but your physician will be there and will order pain medicine for you.
- D. Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.
Correct Answer: B
Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.