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When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?
- A. Household pets
- B. New furniture
- C. Lead-based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: When assessing a child with asthma, it is crucial to gather information about potential triggers in their environment. Household pets, such as cats or dogs, are common triggers for asthma attacks due to pet dander and saliva. This information is essential to identify if exposure to pets at home could be exacerbating the child's asthma symptoms. Choices B, C, and D are less relevant in the context of asthma triggers. New furniture, lead-based paint, and plants like cactus are not typically primary triggers for asthma attacks compared to common allergens like pet dander.
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A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Remove sutures using sterile technique.
- C. Inspect the wound for signs of infection.
- D. Document the removal of sutures.
Correct Answer: B
Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.
A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
- A. smoothie
- B. sliced banana
- C. pancakes
- D. sunny side up (fried) eggs
Correct Answer: D
Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
- A. 2 cups of soup
- B. 1 quart of water
- C. 8 oz of ice chips
- D. 6 oz of tea
Correct Answer: C
Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.
The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?
- A. Place a pillow under the patient's lower legs.
- B. Turn the head toward one side with a large, soft pillow.
- C. Position legs flat against the bed.
- D. Raise the head of the bed to 45 degrees.
Correct Answer: A
Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.
A client who is confused and pulling at the tubing of her IV is being cared for by a nurse. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider?
- A. Place the client in a room away from the nurses' station.
- B. Limit the client's visitors.
- C. Give the client washcloths to fold.
- D. Close the door of the client's room.
Correct Answer: C
Rationale: Providing the client with washcloths to fold is a non-restrictive intervention that can help distract and engage the client, potentially reducing the need for restraints. This action promotes a therapeutic and calming environment for the confused client. Placing the client in a room away from the nurses' station (Choice A) may not address the underlying issue of confusion and agitation. Limiting the client's visitors (Choice B) may not directly assist in managing the client's behavior. Closing the door of the client's room (Choice D) does not actively engage the client in a therapeutic intervention to address the behavior.