Nokea
A 3-year-old girl with complaints of dysuria. The physician orders a catheterization to obtain a urine specimen.
The nurse should
- A. describe the procedure to the child in short, concrete terms while talking calmly.
- B. let the child play with the equipment during the procedure.
- C. involve the girl's older sister in explaining the procedure.
- D. show the child a diagram of the urinary system.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-children this age need simple explanations (2) might contaminate the equipment, must be a sterile procedure (3) not likely to listen to sister (4) not appropriate for this age
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The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
The client is taking streptomycin, isoniazid, and rifampin (Rimactane). Which statement indicates toxicity to isoniazid?
- A. My ears ring all the time.
- B. I have sharp pains in my legs.
- C. My urine is orange-colored.
- D. I'm having trouble at traffic lights.
Correct Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, manifesting as sharp leg pains. Tinnitus is linked to streptomycin, orange urine to rifampin, and color vision issues are unrelated.
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.
A client receiving Gentamycin (garamycin) IVPB has a morning peak level of 12 μg/mL. The nurse should:
- A. Notify the physician because the level is too high.
- B. Administer the medication at the scheduled time.
- C. Request an order to administer the medication IM.
- D. Repeat the level 30 minutes before the next dose.
Correct Answer: A
Rationale: The nurse should notify the physician because the level is too high (therapeutic range for Garamycin is 4-10 μg/mL). Answers B and C are incorrect because they would increase the peak level. Answer D refers to the time for drawing a trough level, making it incorrect.