Nokea
The school nurse is teaching a group of preschool mothers about poison prevention in the home.
- A. Which statement by a mother indicates that further teaching is necessary?
- B. I should have a bottle of Ipecac for each of my children.'
- C. I should induce vomiting if my child swallows lighter fluid.'
- D. Giving my child water or milk may help dilute the poison.'
- E. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. The other statements are correct: Ipecac is recommended for emergency use, diluting with water or milk can help, and proper storage is essential for prevention.
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The nurse is caring for a client who has a cervical radioactive implant. Which action is not appropriate for the nurse when caring for this client?
- A. Post a radioactive symbol on the client's chart and on the door to the room.
- B. Put on gloves to remove any radioactive implant that may have come out.
- C. Wash hands with soap and water after caring for the client.
- D. Limit the amount of time with the client.
Correct Answer: B
Rationale: Removing a radioactive implant requires specialized handling, not just gloves, to avoid exposure, making this action inappropriate.
An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid lying down for 2 hours after eating.
- B. I should eat smaller, more frequent meals.
- C. I should avoid drinking coffee in the evening.
- D. I should sleep on my right side to reduce reflux.
Correct Answer: D
Rationale: Sleeping on the right side can worsen GERD by allowing acid to reflux into the esophagus; the left side or head elevation is preferred. Options A, B, and C are correct: avoiding lying down post-meal, eating smaller meals, and avoiding coffee reduce reflux.
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 client who is receiving a continuous IV infusion of furosemide (Lasix) for heart failure. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication of furosemide, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.