Nokea
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.
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A four-year-old child with sickle cell anemia.
The nurse is aware that which of the following statements, if made by the parents of a four-year-old child with sickle cell anemia, indicates a need for further teaching?
- A. When my daughter complains of pain, I give her baby aspirin.'
- B. I try to keep my daughter away from people with infections.'
- C. I sometimes have to give my daughter some of her Demerol for pain.'
- D. I encourage my daughter to drink a lot of water.'
Correct Answer: A
Rationale: Strategy: 'Need for further teaching' indicates you are looking for an incorrect behavior. (1) correct-aspirin can cause a hemorrhage during a sickle cell crisis (2) important for a sickle cell client to prevent sickling crisis (3) reflects appropriate use of medication to decrease the client's pain (4) important for a sickle cell client to prevent sickling crisis
A patient with hyperparathyroidism.
Which symptom is MOST important for the nurse to report to the next shift?
- A. Abdominal discomfort.
- B. Hematuria.
- C. Muscle weakness.
- D. Diaphoresis.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct-hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.
A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.