Nokea
A child admitted with failure to thrive has just had a positive sweat Test .
The nurse would anticipate which of the following changes in the child's plan of care initially?
- A. Administration of replacement enzymes.
- B. Administration of oxygen.
- C. A salt-restricted diet.
- D. Initiate intravenous therapy.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-sweat Test is a positive finding for cystic fibrosis (2) no data in this situation to indicate that the child is having pulmonary problems (3) salt is increased in diet (4) no need for IV therapy based on the data in situation
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A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A. Listen to the patient's breath sounds and report back to me.'
- B. Set up the patient's lunch tray.'
- C. Obtain a diet history from the patient.'
- D. Instruct the patient to balance rest and activity.'
Correct Answer: B
Rationale: standard, unchanging procedure; decrease cardiac workload
Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
The nurse is caring for a client who had a transurethral resection of the prostate yesterday.
- A. What is the most concerning symptom in a client one day post-transurethral resection of the prostate?
- B. Urine output of 150 cc over 8 hours.
- C. Bladder spasms and urgency.
- D. Bright red urine with small clots.
- E. Burning on urination.
Correct Answer: A
Rationale: A urine output of 150 cc over 8 hours is critically low, indicating possible obstruction, bleeding, or renal impairment, requiring immediate intervention. Bladder spasms, bright red urine with clots, and burning are expected post-procedure but should be monitored.
The nurse is caring for a man who has chronic emphysema and is receiving oxygen at 2 L/min. The nurse enters the room to find that his wife has turned the oxygen up to 10 L/min because her husband is having increasing difficulty breathing. What is the best immediate action for the nurse to take?
- A. Explain to the wife that his oxygen was ordered at 2 L/min and it should stay there until the physician orders something else
- B. Turn the oxygen setting back to 2 L/min
- C. Tell the wife that 10 L/min is too high and turn it back to 5 L/min
- D. Assure her that 10 L/min will ease her husband's breathing
Correct Answer: B
Rationale: High oxygen in emphysema can suppress respiratory drive, worsening hypercapnia; returning to 2 L/min is critical, followed by physician consultation.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid drinking alcohol while taking this medication.
- B. I should take this medication with food.
- C. I should report any bruising to my doctor.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping methotrexate when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: alcohol increases hepatotoxicity, food reduces GI upset, and bruising may indicate thrombocytopenia.