Nokea
The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic?
- A. Call the office if the toddler's temperature is higher than 100 F (37.7 C)
- B. Fussiness and anorexia are common for 1 week after immunizations
- C. Redness at the injection sites and a mild fever are common
- D. The toddler's activity level should be restricted for 24 hours
Correct Answer: C
Rationale: Redness and mild fever (C) are common post-immunization reactions. A temperature above 100 F (A) is too low a threshold for concern, fussiness for a week (B) is excessive, and activity restriction (D) is unnecessary.
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An adult is admitted with nausea, vomiting, and diarrhea. The client is receiving an IV of dextrose 5% in water with 40 mEq of KCl. The nurse knows the potassium is added to do which of the following?
- A. Replace potassium lost because of vomiting and diarrhea
- B. Replace potassium that the client is not getting from his diet
- C. Stop the nausea
- D. Stop the diarrhea
Correct Answer: A
Rationale: Vomiting and diarrhea cause significant potassium loss, requiring IV potassium replacement to prevent hypokalemia.
The nurse is reinforcing teaching about hypoglycemia with a group of clients who have type 1 diabetes mellitus. Which of the following should the nurse include as signs or symptoms of hypoglycemia? Select all that apply.
- A. Diaphoresis
- B. Flushing
- C. Pallor
- D. Polyuria
- E. Trembling
Correct Answer: A, C, E
Rationale: Diaphoresis (A), pallor (C), and trembling (E) are signs of hypoglycemia due to sympathetic activation. Flushing (B) and polyuria (D) are not typical.
Which test for diabetes measures the long-term management of the disease?
- A. Fasting blood sugar
- B. Glucose tolerance test
- C. Finger stick glucose test
- D. Glycosylated hemoglobin
Correct Answer: D
Rationale: Glycosylated hemoglobin (HbA1c) measures average blood glucose over 2-3 months, assessing long-term diabetes control, unlike fasting, tolerance, or finger stick tests, which are short-term.
A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?
- A. I have signed up to be a dog walker when I normally would watch television.'
- B. I understand that losing weight would improve my health and well-being.'
- C. I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks.'
- D. My spouse and children are always encouraging me to eat healthier.'
Correct Answer: A
Rationale: Signing up as a dog walker (A) shows a concrete behavioral change, indicating readiness. Understanding benefits (B), short-term goals (C), or external encouragement (D) are less indicative of sustained motivation.
A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.