Nokea
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
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Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.
The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.
Which of the following observations is MOST important for the nurse to report to the next shift?
- A. The client indicates the need to use the bathroom.
- B. Blood pressure has decreased from 140/80 to 90/60.
- C. Respiratory rate has increased from 16 to 24.
- D. The client indicates that the chest pain has subsided.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.
The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
- A. Heart rate of 120 bpm.
- B. Respiratory rate of 20 breaths/min.
- C. Oxygen saturation of 95%.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.
A client has a chest tube inserted for treatment of a hemothorax.
Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?
- A. 15-cm of water is present in the suction control chamber.
- B. Constant bubbling is observed in the water seal chamber.
- C. 2-cm of water is present in the water seal chamber.
- D. Clots of blood are observed in the collection chamber.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the patient (2) correct-would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding