Nokea
When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?
- A. Use medications to lower the temperature set point
- B. Apply extra layers of clothing to prevent shivering
- C. Immerse the child in a tub containing cool water
- D. Give a tepid sponge bath prior to giving an antipyretic
Correct Answer: A
Rationale: Use medications to lower the temperature set point. Antipyretics effectively reduce fever by adjusting the hypothalamic set point, preventing complications like seizures.
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The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
An adult is on a clear liquid diet. Which food should the nurse offer him?
- A. A milkshake
- B. Fruited gelatin
- C. Sherbet
- D. Apple juice
Correct Answer: D
Rationale: Apple juice is a clear liquid, appropriate for a clear liquid diet. Milkshakes and sherbet contain dairy, and fruited gelatin may have solids, making them unsuitable.
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.
An adult is admitted in diabetic ketoacidosis. What observation by the nurse is consistent with the diagnosis?
- A. Deep respirations
- B. Foul breath
- C. Constipation
- D. Red rash
Correct Answer: A
Rationale: Deep, rapid (Kussmaul) respirations are a compensatory mechanism in diabetic ketoacidosis to eliminate excess CO2, correcting acidosis.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client.
- A. What should the nurse do before administering prochlorperazine 10 mg IM and Stadol 2 mg IM?
- B. Obtain respirations and temperature.
- C. Dilute with 9 ml of NS.
- D. Draw the medications in separate syringes.
- E. Verify the route of administration.
Correct Answer: C
Rationale: Prochlorperazine (Compazine) is incompatible with other medications in the same syringe, so it must be drawn and administered separately from Stadol. Monitoring vital signs (e.g., blood pressure for orthostatic hypotension) is important but not the priority before administration. Dilution and route verification are unnecessary.