Nokea
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
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A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
- A. Which nursing action is the highest priority for a woman in labor with a sickle cell crisis?
- B. Administer oxygen.
- C. Turn her to the right side.
- D. Provide adequate hydration.
- E. Start antibiotics.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Which of the following client statements indicates to the nurse that teaching has been successful?
- A. I need to call my doctor in a few weeks for a follow-up appointment.'
- B. I need to keep my doctor's appointment next week for a blood Test .'
- C. I can take over-the-counter sedatives if I have trouble sleeping.'
- D. I can drink alcohol as long as I drink in moderation.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol
The nurse is assessing a client with suspected appendicitis.
- A. Which finding supports a diagnosis of appendicitis in a client with right lower quadrant pain?
- B. Pain relieved by lying in a supine position.
- C. Positive rebound tenderness at McBurney’s point.
- D. Absence of bowel sounds on auscultation.
- E. A white blood cell count of 8,000/mm³.
Correct Answer: B
Rationale: Positive rebound tenderness at McBurney’s point is a hallmark of appendicitis, indicating peritoneal irritation. Supine positioning may worsen pain, absent bowel sounds suggest obstruction, and a normal WBC count does not rule out appendicitis.