When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.
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During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.
A primipara presents one week after delivery. She is tearful,has spells of cry and lack of appetite and sleep. What is the most likely diagnosis:
- A. Anaemia.
- B. Post-natal depression.
- C. Schizophrenia.
- D. Maniac disorders.
- E. High grade fever.
Correct Answer: B
Rationale: Post-natal depression is common in the first weeks postpartum presenting with tearfulness appetite loss and sleep disturbances. Other diagnoses are less likely without specific symptoms.
Which response by the nurse best explains why aspirin is preferred to acetaminophen (Tylenol) in the treatment of rheumatic fever?
- A. Aspirin controls fever better.
- B. Aspirin prevents infections.
- C. Aspirin relieves joint inflammation.
- D. Aspirin prevents cardiac enlargement.
Correct Answer: C
Rationale: Aspirin is preferred in rheumatic fever due to its anti-inflammatory properties, which relieve joint inflammation and pain associated with polyarthritis. Acetaminophen lacks significant anti-inflammatory effects, making aspirin more effective.
Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.